2 * * * * * * * * * * * 7 8 9 10 11...2019/09/03 · MR. HANNAH: Dave Hannah with Passport. MR. CAIN: Micah Cain with Passport. MS. WHITE: I'm Shannon White with Centerstone Kentucky

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DEPARTMENT OF MEDICAID SERVICES BEHAVIORAL HEALTH TECHNICAL ADVISORY COMMITTEE

Capitol Annex

702 Capital Avenue, Room 125 Frankfort, Kentucky

September 3, 2019

commencing at 1:00 p.m.

Jolinda S. Todd, RPR, CCR(KY) Registered Professional Reporter

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A T T E N D A N C E

TAC Committee Members:

Sheila A. Schuster, PhD, Chair

Valerie Mudd

Mike Barry

Steve Shannon

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MS. SCHUSTER: All right. Good afternoon.

If you are here for the Behavioral Health

TAC meeting, you are in the right place at

the right time so welcome. And let's go

around and do introductions as we usually

do. And we'll start in the far corner over

there with Dr. --

MS. McKUNE: Hi, I'm Liz McKune with

Passport Health Plan.

MR. HANNAH: Dave Hannah with Passport.

MR. CAIN: Micah Cain with Passport.

MS. WHITE: I'm Shannon White with

Centerstone Kentucky. I'm hiding in the

corner back here.

MS. SCHUSTER: Shannon doesn't want anybody

to ask her anything about Supreme Court

rulings.

How about up here in the front?

PARTICIPANT: Thanks for bringing it up.

MR. BLACKBURN: Shan Blackburn from the

Pathways.

MR. KELLY: Marc Kelly, Pathways.

MS. LAKES: Anita Lakes, New Beginnings.

MR. BARRY: Mike Barry, PAR, People

Advocating Recovery.

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MR. SHANNON: Steve Shannon, KARP, member

of the TAC.

MR. JOHNSON: Dustin Johnson with Aetna.

MS. BOWLING: Sarah Bowling with Aetna.

MS. STEARMAN: Liz Stearman with Anthem.

MR. RUDD: Andrew Rudd, Anthem.

MS. SCHUSTER: Okay.

MR. WICKEY: Bert Wickey, Johnson &

Johnson.

MS. JESSEE: Rebecca Jessee, Janssen.

MR. BALDWIN: Bart Baldwin, Kentucky Health

Resource Alliance, United Kentucky.

MS. SCHUSTER: You're sitting in for --

MR. BALDWIN: -- and the other behavioral

health stuff.

MS. SCHUSTER: -- for Sarah --

MR. BALDWIN: Yeah.

MS. SCHUSTER: -- who is still out on

maternity leave; right?

MR. BALDWIN: Yes.

MS. SCHUSTER: Okay.

MR. CALLEBS: Johnny Callebs, The Columbus

Organization.

MS. HASS: Mary Hass. I'm with the Brain

Injury Association, Kentucky Chapter

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Legislative Advocate.

MS. ABBOTT: Susan Abbott, P&A.

MS. SHUFFETT: Christy Shuffett, New

Beginnings.

MS. LOY: Beverly Loy, Adanta.

MS. SAVAGE: Meg Savage, Kentucky Coalition

Against Domestic Violence.

MS. SCHUSTER: Yeah, we got them over

there.

PARTICIPANT: Oh, you do?

MS. SCHUSTER: Yeah.

PARTICIPANT: I'm sorry.

MS. PAXTON: Julie Paxton, Mountain

Comprehensive Care Center.

MS. ADAMS: Kathy Adams, Children's

Alliance.

MS. SANDWOOD: Michelle Sanborn, Children's

Alliance.

MS. GUNNING: Kelly Gunning, NAMI Lex.

MS. MUDD: Valerie Mudd, NAMI Lexington,

Participation Station and member of the

TAC.

MS. JOHNSON: Ramona Johnson, Bridgehaven

in Louisville, Kentucky.

MR. BALDWIN: Brad Leedy with Bridgehaven.

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MS. SCHUSTER: Great.

PARTICIPANT: We've got some people --

MS. SCHUSTER: Oh, I'm sorry.

MR. VENNARI: Joe Vennari, Humana

CareSource.

MS. MOWDER: Kristan Mowder, Humana

CareSource.

MS. SCHUSTER: Okay, great. So we have a

quorum. We have Valerie Mudd, Steve

Shannon, Mike Barry and myself as members

of the TAC. Gayle DiCesare had e-mailed me

and said she had to go out of town. And

Sarah is still on maternity leave.

So I sent out to you-all -- and you

also have it in your packet, the minutes

from the July 9th Behavioral Health TAC

meeting, which we adopt from the report that

was given by Steve Shannon at the July 25th

MAC meeting. So I would entertain a motion

from one of the TAC members to approve the

minutes.

MS. MUDD: So moved.

MS. SCHUSTER: Valerie.

MR. SHANNON: Second.

MS. SCHUSTER: And Steve second. All in

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favor signify by saying aye.

PARTICIPANTS: Aye.

MS. SCHUSTER: And opposed, like sign.

(No response.)

MS. SCHUSTER: All right. Thank you very

much.

Steve, was there any report you wanted

to make from the July 27th, MAC meeting?

MR. SHANNON: No.

MS. SCHUSTER: There was no report?

MR. SHANNON: The report was given. It was

a wonderful experience for KARP.

MS. SCHUSTER: Let the record show that

Steve really enjoyed the experience. We

might let him do it again since he enjoyed

it so much.

Welcome, we've got sign-in sheets.

Hi, Abner. And handouts here.

(Dr. Rayapati enters the meeting.)

MS. SCHUSTER: And I sent you-all -- I

believe I sent those out, the responses

from DMS to our July recommendations. They

were received with great acclaim. Not.

So the Commissioner was very clear in

telling us that we are not advisory to

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Medicaid. We are advisory only to the

Medicaid Advisory Council, which is advisory

to Medicaid. Now, I see that as at least

being advisory once removed, but apparently

that is not.

MS. MUDD: We have to take an extra step

up, I think.

MS. SCHUSTER: Yeah, that's not what the

Commissioner wanted to share with us. This

was in -- you know, we've made this

recommendation before, that it would be

super helpful if the Medicaid Department

would discuss with us, since we have some

expertise in this area, some of the changes

that they are proposing, either in

regulations or in rates or any number of

things, change in policy, and let us

respond to it beforehand, as opposed to

after it's in place and then everybody is

upset and coming back and responding to it

then. But it doesn't look like that's

going to happen.

MS. SANBORN: Can they respond to the MAC?

MS. SCHUSTER: I'm sorry?

MS. SANBORN: Why would they respond to the

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MAC if they don't want to respond to the

TAC? If they respond to the MAC, would --

isn't that the purpose of that group?

MS. SCHUSTER: You know, the MAC has raised

that issue, Michelle, a number of times.

And, in fact, if you go back to the

Medicaid waiver, the creation of Kentucky

Health, the MAC was very upset about the

fact that they are advisory and been in

statute for years and years and years and

had not been notified by DMS that there was

any work going on to develop a waiver that

was going to significantly change Medicaid.

And there's not been any response from

Medicaid to that, nor has there been since

then. So I think we can continue to raise

the issue of the -- you know, if you go to

those MAC meetings -- and I missed the one

in July. But, generally speaking, the

Commissioner comes up and responds to

things that are on the agenda without a

whole lot of give and take with the rest of

the MAC, and almost no give and take -- or

actually none, with what the TACs are

recommending or saying.

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MR. SHANNON: There's no discussion.

MS. SCHUSTER: I mean, there really is no

discussion.

MR. SHANNON: MAC members may ask a

question, but Medicaid never answers.

MS. SCHUSTER: Never answers. Yeah. And

we -- you know, if you've been to those

meetings, when you come up to give your

report, you're really giving your report to

the MAC. You're not giving your report to

the -- to the Medicaid staff. Although,

I've been known to turn and look at them

and say things to them while I'm giving

them my report, because there are things

that we're saying that have to do with

them. But there really is no format for

any real give and take.

Now, you remember at the MAC meeting,

maybe back in March, that the MAC did point

out to DMS that they were not responding

very positively to any of the

recommendations from any of the TACs and

they gave some examples. I think several of

ours were on there, as well as some to the

consumer TAC, which they have routinely kind

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of dissed. And, actually, I don't think

anything really came of that, you know, they

kind of heard it and then went on.

I don't know if there's a

recommendation that we can make.

MS. MUDD: Listen to us.

MS. SCHUSTER: (Laughs). A plea from the

people. You know, to make them more

responsive or -- or interactive.

You know, this Commissioner, for

whatever reason, has kind of taken it on as

a personal mission to I think interact very

negatively with the TACs. I didn't print

out for you-all, but they sent a response.

The MAC asked the Attorney General for an

opinion about teleconferencing. And the

Attorney General essentially said, yes, you

can still have an open meeting and meet open

meeting requirements and have

teleconferencing. And when they sent that

out, there was a memo from the Commissioner

that essentially said, yeah, you can do it,

but we're not going to help at all. We're

not going to help you set it up. We're not

going to maintain it or make sure that it

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meets the requirements. And then it was

followed up with a e-mail from Charlie

Hughes, who is kind of the liaison with the

TACs, saying if you really want to do it,

you would have to work with the IT people

over at the Cabinet and it's $75.00 an hour

to get their consultation and --

MS. MUDD: Ridiculous.

MS. SCHUSTER: -- you know, this, that and

the other thing.

MR. SHANNON: And I think some TACs will

pay it or they will do it themselves and

have the technology. I think the ones that

don't, it -- it creates an unlevel playing

field.

MS. SCHUSTER: Yeah. So we've never pushed

it.

MR. SHANNON: Helps the physicians, as

opposed to driving to a meeting.

MS. SCHUSTER: Yeah, I think the physician

would do it. The Consumer TAC is looking

at it very strongly, because they have a

consumer member who needs attendant care

and the Cabinet has refused to make any

arrangements to pay for that attendant

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care, and so it's very difficult for that

individual to participate. And usually P&A

has some staff there to help. And the last

time they had attendant care there and I

don't know who paid for it. I'm sure the

consumer does not have the funds to do

that. And so they're looking, I think,

very strongly at perhaps doing

teleconferencing for the Consumer TAC to

make it easier for people with disabilities

to participate.

We've never done it in part, because

we've always gathered a fairly large group

and we've not had trouble getting a quorum.

Most of our TAC members are in the golden

triangle and so forth. Gayle is the

furthest one now, from Owensboro, but --

suffice it to say that there's not a very

positive working relationship, from my

perspective any way, between DMS and the --

and the TACs in terms of how we do our --

our business.

MS. HASS: Well, Sheila, don't take it

personally if she doesn't have a -- you

know, I used to have a monthly meeting.

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And all those have been cancelled, so you

know --

MS. SCHUSTER: With -- with the Medicaid

Commissioner?

MS. HASS: Basically since Carol came on.

MS. SCHUSTER: Well, it's unfortunate,

because like in this next one we're talking

about regulations, like these BHSO Regs

that we've talked about now in two

different meetings. We're going to talk

about it again today. And it caused such a

stir both the mental health BHSOs and the

substance abuse disorder BHSOs, and really

threatened the livelihood of peer support

folks and their ability to maintain

full-time employment while they're in

recovery and working as a --

MS. GUNNING: Well, I mean, they provided

the services.

MS. SCHUSTER: Yeah, yeah. So she went

through, you know, all the -- all the steps

that they had gone through and so forth. I

was underwhelmed.

PARTICIPANT: That wasn't even accurate --

MS. SCHUSTER: We recommended --

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PARTICIPANT: -- that's true.

MS. SCHUSTER: We recommended something on

KI-HIPP, and they did get a frequently

asked questions document. There still are

lots of questions being raised by some

outside groups, like Kentucky Voices for

Health, about whether KI-HIPP is really a

program that we want to encourage people to

participate in or not. And we raised,

again, some concerns about the copays,

particularly those below 100 percent of the

federal poverty level.

MR. SHANNON: In her comment was the first

time I heard it articulated that way.

MS. SCHUSTER: Which was?

MR. SHANNON: That they have a copay, but

it can believe waived. They can't be

denied services.

MS. SCHUSTER: They cannot be denied

services.

MR. SHANNON: So they still -- so they can

accumulate copay debt, essentially.

MS. SCHUSTER: Well, and there's been

some --

MR. SHANNON: Which is meaningless.

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MS. SCHUSTER: -- some question raised by

some attorneys about whether providers

would be in a position to go after people

if they have continuous lack of copay

payments and they've accumulated a good bit

of debt and whether that would affect

somebody's credit rating, if they have a

credit rating, and some of those kinds of

things that could really put people in

jeopardy. So, yeah, I thought, Steve, that

they didn't have a copay and could not be

denied services.

MR. SHANNON: They have -- they have a

copay.

MS. SCHUSTER: They have a copay.

MR. SHANNON: They must get services.

MS. SCHUSTER: Yeah.

MR. SHANNON: And they're going to owe

someone $3.00.

MS. SCHUSTER: Yeah. And then we, again,

tried to ask about the 1915(c) waiver

design panels and having access to those

people. And I think they want us to

still -- I'm assuming, Mary, this response

essentially says continue to e-mail.

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MS. HASS: Yes.

MR. SHANNON: Mystery box.

MS. SCHUSTER: Mystery box, yeah.

MS. HASS: Yeah, state your complaint, then

you can -- they would open up the

complaint -- not the -- not the complaint,

excuse me, the comment line. And that it

was still open and I could voice my

concerns there.

MS. SCHUSTER: This last one, Marc, is that

issues that you brought up at the TAC

probably four months ago --

MR. KELLY: Uh-huh (affirmative).

MS. SCHUSTER: -- two meetings ago or so.

Do you have any information about anybody?

I mean, do you have -- what they're saying

is they can't do anything about it until

they have a name and a date and, you know,

a person who was denied transportation.

MR. KELLY: I can come up with that.

MS. SCHUSTER: Well, I think that's the

only way that we're going to push the

envelope on this.

Julie, I think when we talked about

this four months ago, you said that that

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happened sometimes in your region, too, in

Mountain, where you have somebody at a --

say a hospital that doesn't have a psych

unit and needs to get transported, a mental

health patient.

MS. PAXTON: -- transportation issue.

MS. SCHUSTER: And the transportation

issues. I think the only way that we're

going to get on that is to literally get

the Medicaid member's name, serial number,

all that kind of stuff, and a date when

they were denied service. And I think it's

an issue well worth pushing.

MR. KELLY: Yeah, I agree.

MS. SCHUSTER: Now, DMS says that they will

do something about it if we get them that

information. So we might reach out, Steve,

also, and, Bart, to some other comp care

centers, because I think -- particularly

the ones out in rural areas are definitely

experiencing this.

We also heard from Beth Partin, who is

the chair of the MAC and has her own rural

health clinic out in Adair County, that it's

happening at primary care settings. So they

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have people that are there, have a mental

health crisis, they can't get anybody to

come and pick them up. So I think we're

going to have to do some reaching out and

get people -- it would be very helpful if

you report something directly to Medicaid,

if you would let me know. I don't need to

know the person's name, but I'd like to be

able to document that Pathways had two or

three people and Mountain had, you know,

three or four people and on these dates

you-all sent that information in. Because

otherwise, there's no way to hold them

accountable to do anything.

MR. KELLY: Yeah, I thought they would want

something specific, case specific, so...

MS. SCHUSTER: Yeah, yeah. So you're going

to have to have at least a name and a

Medicaid number and a date when they were

denied and maybe the location. Is that

doable, Julie, you think?

MS. PAXTON: I think so.

MS. SCHUSTER: Okay. Bart, I'll do up an

e-mail or something. We'll send it out.

You can send it to your folks and Steve

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will send it out as well, because I think

we ought to stay on this because this -- to

me it's a really important issue for us to

pursue.

MS. GUNNING: Sheila, is the only -- the

only issue with the private ambulance

company, is that they don't have a payer

source? Because I was -- that was not my

understanding. These are private

businesses, right, that are refusing to

transport people? And is their only reason

for refusing the transport is that there's

no payer source?

MR. KELLY: What they say is if they're

ambulatory, that they can't transport.

MS. GUNNING: That's what the problem is.

And these are private businesses. I mean,

I don't really know what dog DMS has in

that fight. It's really policy that's the

problem.

MR. KELLY: Well, the client's a Medicaid

recipient.

MS. GUNNING: Yeah.

MR. KELLY: Medicaid would be the payer.

MS. SCHUSTER: Yeah.

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MS. GUNNING: But that's not why they're

refusing to transport them.

MS. SCHUSTER: Well, no, but when you first

brought it up you were being told, oh, no

we don't have to take mental health

patients.

MR. KELLY: That's -- that's --

MS. GUNNING: That's what I mean. Is that

the problem or is it --

MR. KELLY: That's exactly what they were

saying.

MS. GUNNING: -- or is it the payer source?

MR. KELLY: That's what I was told first.

They don't transport any mental health

patients.

MS. GUNNING: Well, that's a

discrimination.

MR. KELLY: And I said, well --

MS. SCHUSTER: Exactly. That's why we

brought it up so strongly.

MS. GUNNING: I mean, it's more of a

discriminatory thing than it is a DMS

issue.

MR. KELLY: Yeah. And I said, well, why?

And they said, well, if they're ambulatory,

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we don't have to transport. That was

all --

MS. GUNNING: I'm wondering if that.

MR. KELLY: -- based on --

PARTICIPANT: They transport lots of people

who are ambulatory but have medical issues.

MS. GUNNING: That's right.

MR. KELLY: Sure.

MS. GUNNING: It's a parity issue and a

discrimination issue.

MS. SCHUSTER: Yeah, so we're going to need

to know what that reason for denial was,

because we were first told that, oh, no, I

don't have to transport them if they're

mental health. But I think we're -- we're

only talking about the Medicaid folks. I

mean, we can't --

MR. KELLY: Right.

MS. SCHUSTER: -- deal with people that

have private insurance who are not

Medicaid.

MS. GUNNING: Right.

MS. SCHUSTER: But the only way we can get

Medicaid to look at it is --

MS. GUNNING: But I think the -- that they

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don't want to deal with a group of people

that can be problematic.

MR. KELLY: Well, they said regulation.

They said it's the regulation.

MS. GUNNING: What regulation?

MR. KELLY: Well, that's -- yeah, that's

what I was getting ready to ask. Is it a

Medicaid regulation? Is it a --

MS. GUNNING: I think it's their own

private policy.

MR. KELLY: Is it a licensure regulation?

I guess that would be a -- I don't know.

PARTICIPANT: Unless -- well, there could

be regulations for emergency medical

services providers.

MS. GUNNING: But I don't think they can do

that.

MR. SHANNON: You take Medicaid, you take

Medicaid.

MS. SCHUSTER: Yeah, I was going to say, if

you take Medicaid, you take Medicaid. I

think that's right.

MR. SHANNON: They said they would --

PARTICIPANT: Right. If the client doesn't

meet medical necessity because

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they're ambu- -- that word.

MR. KELLY: Ambulatory.

PARTICIPANT: There we go. Then that's why

they're using that as the reason that we

don't have to transport them. Medicare is

not going to cover it. It comes back to

your point, there's no payer source.

MR. KELLY: I got different answers from

different --

MS. GUNNING: Of course, you will.

They're --

MR. KELLY: -- because it was a safety

issue, was one. And then we never

transport mental health patients because

that's a 202A. I said, no, this is

involuntary admission.

MS. GUNNING: Right.

MR. KELLY: And they said, well, we've

never transported mental health patients

before. I'm like...

MS. SCHUSTER: That's what I'd like to nail

them on, is that one.

MR. KELLY: Yeah.

MS. GUNNING: That's the key.

MS. SCHUSTER: Because that's -- that's

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really discriminatory.

MS. GUNNING: Yes.

MS. SCHUSTER: Okay. Well, let's -- if

you-all would go back and see what you can

document, I think would be the case and let

me know.

MR. KELLY: Be easy to find out

MS. SCHUSTER: Okay. Thank you.

MS. GUNNING: Because their license might

be, you know, suspended if they're

practicing discriminatory things against

certain classes of patients.

MS. SCHUSTER: Well, and I think when we

talked before -- because I think Sarah was

here and said, let's find out what the reg

is. If the problem is in the reg, then

let's push for some change in the wording

to make sure that it encompasses people

with mental health issues.

MS. MUDD: And it should be just like any

other ambulatory service, I would think,

that if a patient is -- is admitted then

that is covered; right?

MS. SCHUSTER: Right. Yeah, should be.

PARTICIPANT: Well, I guess that falls

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under whether it's an emergency or not.

Because I can see where they're saying it's

not medical -- medical necessary for the

emergency transport, but they need a

transport for a voluntary. So it's kind of

splitting hairs.

MR. KELLY: It's a brain emergency.

PARTICIPANT: Huh?

MR. KELLY: It's a brain emergency.

PARTICIPANT: Well, I know. I'm being --

MR. KELLY: Oh, yeah, I know

MS. GUNNING: It's interesting how it's

different from county to county.

PARTICIPANT: If you don't understand what

you're dealing with, why -- why you would

think that.

MS. SCHUSTER: Right.

PARTICIPANT: Not that it's allowable. I'm

just trying to think how -- it's part of

the problem. You know, it may not even be

a Medicare reg. But that's okay. We can

work on that one, too.

MS. GUNNING: I think it's a company issue.

MS. SCHUSTER: Well, I think it may very

well. And it may have a historic --

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they've never done it, so they're not going

to start now kind of thing, or somebody

said, oh, you don't have to do that, so --

well, it was --

MR. KELLY: You know, it was a forceful

response, like they had said that several

times, you know. That was the stock

response, you know, right away.

MS. SCHUSTER: All right. Well, let's --

let's pursue that.

Speaking of regs, we have some

concerns about the BHSO regs. We talked

about them at some length last meeting and

the meeting before. I asked Ramona and Brad

to come, because probably Bridgehaven as a

mental health BHSO is just affected as

anybody. You want to talk about what

your -- what you submitted in terms of your

response or what the situation is for

you-all, Ramona?

MS. JOHNSON: Yeah, there are -- there are

a number of issues with the regulations,

but the two primary issues that are the

most concerning is that when they started

writing the regs for the substance use

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providers, BHSO 2 and 3, the original BHSO

regs had language in it that treated people

with severe mental illness and

co-occurring, secondary substance use

disorders. So every -- every reference to

treating a co-occurring disorder, somebody

with a primary severe mental illness has

been stricken from those regulations. So

that puts a BHSO 1, who is treating people

with severe mental illness, who over

50 percent report initially that they have

some form of substance use problem; more

than that after we get them into treatment,

we find out. And we address that

through -- simultaneously in the program,

in our program with dual diagnosis groups,

et cetera. They remove CADC counselors as

billable providers from the BHSO 1 regs.

That's an issue for the substance use

people, too, I believe.

MS. GUNNING: Especially for

co-occurring --

MS. JOHNSON: Yeah.

MS. GUNNING: -- integrated treatment.

MS. JOHNSON: And putting -- putting a

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group of people who have severe mental

illness as their primary diagnosis into the

substance use disorder treatment center

makes no sense at all, because they're not

prepared to deal with the severe mental

illness.

MS. GUNNING: They won't.

MS. JOHNSON: And won't, right. Can't and

won't. I mean, so it kind of -- it leaves

over 50 percent of people with an SMI

unable to access treatment for the

co-occurring substance use in the same

setting, which is the evidence-based

practice that they treat them together.

And I pointed out in both the written

comments that I submitted and then the

comments -- we went to the hearing and made

comments that for people with severe mental

illness, usually their substance of choice,

if you will, is alcohol, maybe cannabis.

You know, they are not the narcotic, they're

not the opioid addicts. They're not the

people who are abusing, you know, Oxycodone

and heroin. They're usually not addicted to

those substances. They have self-medicated

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with alcohol or cannabis to reduce the

anxiety, to dull the voices. And once they

get into treatment to treat those symptoms,

they very often don't feel the need to use

the substance. Many of them quit using on

their own. And the others, we work with to

help them -- in a harm reduction model to

help them deal with that. So I pointed out

that, you know, I know we're addressing --

we have a serious opioid crisis in the

state. And we are fully supportive of

servicing to treat people with that severe

addiction. I mean, it needs to be

addressed, but not at the expense of people

with --

MS. GUNNING: Amen.

MS. JOHNSON: -- a severe mental illness,

who need help with alcohol and marijuana,

makes -- just doesn't make any sense. That

was -- and it's been removed everywhere in

the reg. So with every single service,

it's listed, you know, co-occurring.

MS. SCHUSTER: Co-occurring --

PARTICIPANT: So it's totally out?

MS. JOHNSON: Oh, yeah.

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PARTICIPANT: On one, two and three, or

just the Section 1.

MS. GUNNING: Section 1.

PARTICIPANT: Everywhere.

MR. KELLY: Co-occurring language

removed --

MS. GUNNING: It's removed from two and

three, too.

MR. SHANNON: Yeah, BHSO 1 --

MS. JOHNSON: It's removed from the BHSO 1

regs. Co-occurring disorders are

referenced in the 2 and 3 regs, but not the

SMI part. Just as a co-occurring disorder.

It doesn't say what the rest of it is. And

so my point that I made in writing at the

hearing was that, you know, a simple

language change would -- would fix this.

If you put into the BHSO 1 regs that the

services are provided for people with a

severe mental illness and co-occurring

substance use disorder when severe mental

illness is the primary diagnosis. That's

really all they need to do to allow BHSO 1

to continue treat the population that

we've -- that we're already treating and

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not have those people, really have nowhere

to go.

MS. GUNNING: They have nowhere to go,

right.

MS. JOHNSON: And it's just -- just a

language issue.

MR. BALDWIN: Well, and the other thing we

ran into and made comments on was, you got

somebody that you're treating for mental

illness. And, of course, with the

treatment you find out they have a

substance abuse --

MS. JOHNSON: Right.

MR. BALDWIN: -- issue. It's very common.

MS. JOHNSON: Yeah.

MR. BALDWIN: And at that point, you're a

BHSO 1 --

MS. JOHNSON: Uh-huh (affirmative).

MR. BALDWIN: -- you don't -- you're

not able to --

MS. JOHNSON: Right.

MR. BALDWIN: And so -- but you want to --

like I say, you want to integrate the

service --

MS. JOHNSON: You can't.

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MR. BALDWIN: And it's not like you

can't -- then what do you -- what do you

do? You're instantly out of clients --

MS. JOHNSON: Right.

MR. BALDWIN: -- as soon as you find that

out. So how do you...

MS. GUNNING: And you really can't refer

somebody to a substance use disorder

treatment center when their primary

diagnosis is mental illness.

MS. JOHNSON: No. And if we -- and we do.

I mean, when we encounter somebody when

they've been in treatment for a while with

us and been in recovery program and -- and

occasionally there's somebody we find out

later that they are using heroin. They

are, you know, abusing narcotics. We don't

keep them at Bridgehaven. We refer them on

to a substance use provider and say this

addiction has to be treated before we can

do anything. I mean, because it's --

that's a -- that becomes the primary at

that point.

MR. BALDWIN: Takes away your flexibility

and your ability to integrate care.

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MS. SCHUSTER: Kelly?

MS. GUNNING: What we're seeing in the

mental health court -- and it is a court

where the primary diagnosis is a serious

mental illness to get into the court. What

we're seeing is 80 percent of our people

right now in the court program -- and it's

been as high as 85 percent -- also have a

co-occurring disorder. And many of the

times, unlike what Ramona has seen, we are

seeing -- we're seeing poly substance use

disorder. So we're seeing heroin, we're

seeing methamphetamine, we're seeing

alcohol, we're seeing marijuana, we're

seeing benzos. We're seeing anything

basically the people can get on the street

and get their hands on. And the problem is

when we try to refer them out, because we

can't get them in a BHSO or whatever,

they're not allowed to take their

psychotropic medications and be in many of

those straight-line AODE programs. That's

a violation of the program.

MS. JOHNSON: Right.

MR. CALLEBS: Psychotropics are?

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MS. GUNNING: Yeah.

MR. SHANNON: Medication.

PARTICIPANT: Medications, period.

MS. GUNNING: But the psychotropics for

sure.

MR. SHANNON: Yeah.

MS. GUNNING: We have people actually

honestly hang up on us when they hear their

list of medications. They don't talk to

us. And that's to treat their primary

serious mental illness.

MS. SCHUSTER: Kathy?

MS. ADAMS: One of the issues that has

troubled us and we sent our little question

to the, you know, DMS issues and got a

response back, but we're still not clear.

But it appears that you can only be a BHSO

1 or a 2 or a 3. It's not as if you're a

3, that then you're able to do Tier 1 and 2

services.

MR. BALDWIN: That's right.

MS. ADAMS: So we're trying to get

clarification on that, which would kind of

address Bart's issue. But when they

responded back initially, they use the --

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the word primary. When SUD is primary,

then you have to go to a Tier 2 or a Tier

3. So we've gone back and asked, well,

what if mental health, they're being

treated in a BHSO 1 for mental health and

an SUD comes up, but it's not necessarily

primary, would then they -- could they

still be seen by a 1? So we're trying to

get some clarification. But, again,

they're --

MR. BALDWIN: Right.

MS. GUNNING: The best practice is

integrated treatment and it shouldn't

matter what tier you are.

MS. JOHNSON: Totally agree to that.

MS. SCHUSTER: What it reminds me of is all

the years when Medicaid didn't recognize

SUD.

MS. JOHNSON: Right.

MR. BALDWIN: Right.

MS. GUNNING: Right.

MR. BALDWIN: Yeah.

MS. SCHUSTER: And the CMHCs were seeing

the Medicaid people and they knew that they

had co-occurring and they couldn't speak --

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they could speak to the mental illness, the

depression, but they couldn't speak to the

person self-medicating with alcohol or

other -- other drugs --

MS. GUNNING: It needs to be integrated.

MS. SCHUSTER: -- or they did and they

didn't record it and they couldn't diagnose

it.

MR. SHANNON: Or they did and had a threat

of recoupment.

MS. SCHUSTER: And they had the threat of

recoupment.

MR. SHANNON: Under the Fletcher

administration.

MS. SCHUSTER: We're back in those -- those

days --

MR. SHANNON: Right.

MS. SCHUSTER: -- and the 2s and 3s don't

have the personnel to treat the primary --

MS. GUNNING: No.

MS. SCHUSTER: -- mental illness.

MS. GUNNING: And you can't -- they don't

meet the criteria because of their meds.

So you can't get them in anyway.

MS. SCHUSTER: So what happened at the --

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at the public hearing, Ramona? You had --

MS. JOHNSON: Well, at the public hearing

there may have been other mental health

providers there. The only people I heard

testify were substance use providers

besides Bridgehaven.

MS. GUNNING: When was it?

MS. SCHUSTER: A week ago Monday.

MS. GUNNING: A week ago?

MS. JOHNSON: Last Monday. Well, we barely

found out about it.

MS. GUNNING: I didn't even know about it

or we would have been there.

MS. SCHUSTER: Yeah, I think Ramona found

out about it over the weekend and it was

9:00 on that Monday morning.

MS. GUNNING: Well, that's how they send

out the notices on all these changes.

MS. SCHUSTER: Yeah.

MS. JOHNSON: Yeah, we found out about it

on -- I think it was Friday morning and put

our team together Friday afternoon, got our

talking points together Friday afternoon

and over the weekend, and we were there on

Monday.

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MS. GUNNING: Where was it, Ramona?

MS. SCHUSTER: Over at the Cabinet.

MS. JOHNSON: Over at the CFHF. We took a

team with us. We had our board chair. I

was there. Our chief operating officer and

three peer support specialists. One peer

support specialist who was our team leader.

So he supervises the peers who work on our

program. And our two peers who are -- run

the center for -- where they do all the

peer support training, where they do RAP

training up around the state for peers.

They maintain the central database of peer

support specialists and their contact

information. Technical assistance to

organizations in terms of, you know, how

to, you know, best integrate peer support

services into their programs. All that --

and that part is funded by the Department

of Behavioral Health. So here's the

department wanting peer support services,

evidence-based services and -- and really,

in some cases, pushing the CMHCs to

increase that service and we're -- we're

trying to help do that. We definitely

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integrated them into our services.

And then they write regs that limit

the peer support specialists to 120 units of

service a week. Now, if the peer does only

individual work, then that's probably a

30-hour week and they have a day that they

have, you know, notes and other stuff. So

you got -- that's a full-time position. But

if a peer does groups -- and most of our

peers do a lot of groups, and I would think

that substance use peers would also be

working on -- in a group -- a group format

for the most part. They're going to use up

those 120 units in a day and a half.

MS. GUNNING: Yeah.

MR. SHANNON: Now, we were told the units

for group, you count individuals, but you

really count the time, is what we were

told.

MS. JOHNSON: The what?

MR. SHANNON: Well, if a person has a group

for half an hour, that's two 15-minute

units. You don't count the heads. That's

what Medicaid told us to do. So you don't

go through -- you don't burn through the

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units that way. Even though you bill group

based on the individuals participating, you

count --

MS. JOHNSON: The units --

MR. SHANNON: -- the time -- but you count

the time that they are doing the service.

MS. JOHNSON: Well, that's not clear at

all --

MS. GUNNING: No.

MS. JOHNSON: -- in the regulation.

MR. SHANNON: Well, no. That's why we

asked them the question. That was their

response to us. So we thought the 30 hours

was more than enough, because you're not

going to spend much more than that doing

group or individual anyway. It's not

prudent. So that was what we were told.

But I'll find that e-mail and send it to

you.

MS. JOHNSON: Okay. That's --

MR. SHANNON: But it's clear -- I agree

with you, it wasn't clear --

MS. GUNNING: Could you send it to us, too,

Steve --

MR. SHANNON: Yeah.

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MS. GUNNING: -- because we were told you

do count the heads.

MS. JOHNSON: Yeah. And --

MS. GUNNING: And it's per person.

MS. JOHNSON: -- if you count the heads,

then you --

MR. SHANNON: Yeah.

MS. JOHNSON: -- you're done by a day and a

half --

MR. SHANNON: Yeah, you're done by noon

Tuesday.

MS. JOHNSON: And then peers can't work

full time. Then why are we going out and

training peers to be peer specialists and

then saying, oh, well, but you can't work

full time; you can't make a living at this.

And our point in the hearing and on paper

was that, you know, we're talking about

people who have lived experience, who have

fought their way into recovery from their

mental health -- from their mental illness.

They have maybe started working part time,

maintain their disability and their

benefits, and then decided to go full time

with an organization, go off of disability,

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go with the company's commercial insurance

claim, which isn't that what the

administration wants anyway? They're

working full-time. They're on our

insurance plan. They have a 401(k). They

have other benefits. They -- they've gone

beyond that. They don't want to go back on

disability again. And then they're

saying -- and we haven't -- I mean, we

haven't broadcast this to our peers because

we don't want everybody panicking --

MS. GUNNING: Panicking.

MS. JOHNSON: -- before possibly this can

be worked out. But we did pull in these

three peers because we knew that -- we felt

like they could handle it and, you know,

not spread panic among the peers, but...

MS. GUNNING: What about the rate changes,

too?

MS. JOHNSON: The rate change is a

disaster.

MS. GUNNING: It's a horrible thing.

MS. JOHNSON: Total disaster. Of course,

the group limitation from 12 to eight

decreases your capacity to provide services

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and peers -- serving peer people, so that

means you have to do more groups with

people who can't work full time unless

Steve's interpretation is correct.

MR. SHANNON: Not my interpretation.

MS. JOHNSON: Well, their interpretation --

MR. SHANNON: Medicaid's interpretation --

MS. JOHNSON: Yeah.

MR. SHANNON: -- to me.

MS. JOHNSON: Yeah.

MR. SHANNON: It's not mine.

MS. GUNNING: But it doesn't make sense

with the way they've set up billing for

peers --

MR. SHANNON: I understand.

MS. JOHNSON: We've seen two different

rates. The published rate that's the

Medicaid non-facility or, you know, rates

is a -- is a service rate of like $6.25.

MS. GUNNING: 6.25.

MS. JOHNSON: So if you do a group of eight

people, you earn $50. Well, that's --

nobody can -- nobody can operate like that.

MS. SCHUSTER: Right, right.

MS. JOHNSON: There also was discussion of

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a 15-minute rate of $3.40 something cents,

which was -- by the time you look at that

reduction and you look at the reduction of

the number of people in group, and if the

120 unit limitation worked the way we

thought it did, that was like a 90 percent

reduction in revenue from peer support

services. So once again how can --

MS. GUNNING: Billable peer support.

MS. JOHNSON: Yeah, billable peer support,

so like an agency before to have peer

support specialists on staff. And we know

and we have seen that that's one of the

most effective interventions we have in our

toolkit, is our peer specialists.

MS. GUNNING: Especially in dual diagnosis.

MS. JOHNSON: Well, they are the ones that

make the best connection with the

consumers.


MS. JOHNSON: And so they gave very strong

testimony, I think, in the hearing. One of

them talked about the power of the group

and why it was so important for consumers

to hear another person with lived

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experience say, well, yes, you can live on

your own and you can work even if you hear

voices because I do.

MS. SCHUSTER: Right, which you can't get

anyplace else.

MS. JOHNSON: So those -- there were

other -- there were other issues with the

regs. There were issues with screening and

assessment with BHSO 1, again, taking out

all reference to co-occurring disorders, so

we can only discuss the mental health

disorders. Well, I'm sorry, but we can't

do that.

MS. GUNNING: Which goes totally against

the changes they made three or four years

ago wanting everybody to be dual, SUD

and SMI --

MS. JOHNSON: Well, and that, everybody's

required to be accredited. We're

accredited by KARP. If we did all -- only

for mental health issues, we would not be

meeting the KARP standards, which requires

to do a thorough --

MS. GUNNING: Integrated.

MS. JOHNSON: -- psycho-social assessment,

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look at substance use, look at physical

health issues. I mean, it has to be a

complete and thorough assessment. We can't

just address those issues. Those questions

have to be asked. So I pointed out that

the regulations -- if we comply with that

regulation, which we can't, it will put us

in noncompliance --

MS. GUNNING: In noncompliance.

MS. JOHNSON: -- with the KARP standards.

And, of course, regulations require

accreditation. And then there were some --

there was a set of OIG regs at the same

time that mentioned the BHSO 1s, and

they -- they were different than the regs,

the BHSO regs -- ACT teams, services and

composition of ACT teams.

And then targeted case management was

not included in the BHSO 1 regs. They told

us it wasn't because case management had

their own regulation, so they didn't need to

be in the BHSO regs. But in the OIG reg,

targeted case management was listed. And

the OIG reg is about Behavioral Health

Service Organizations. In that reg they

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removed the targeted case management for

people with SMI, co-occurring disorders and

chronic and complex physical health issues.

And those are -- those are the people that

we need to do case management for.

MS. GUNNING: Those are the most important

people.

MS. JOHNSON: So they just screwed it up

all the way around.

MS. GUNNING: They just decimated it,

actually.

PARTICIPANT: Did you point that out to

them?

MS. JOHNSON: Yes, politely.

MS. SCHUSTER: Well, it sounds like a lot

of people sent in -- you sent in comments,

Bart.

MR. BALDWIN: We sent in comments.

MS. GUNNING: I would have if I had known.

MS. JOHNSON: And there were a number of

substance use providers at the hearing, who

talked -- of course, their biggest issue

was requirement for the physician to be an

addictionologist.

MS. GUNNING: Yes. Psychiatrist.

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MS. JOHNSON: But they can't make that

happen immediately.

MR. SHANNON: Can't find them.

MS. JOHNSON: They're not there. They --

MR. SHANNON: They're -- they're hiding.

MS. JOHNSON: -- a certain number of months

or years, or whatever the requirement is,

to even take the test. So they can't meet

that. And the other -- and their other

issue was the peer -- the peer support

restrictions, so...

MS. SCHUSTER: And, Kathy, some of you're

groups sent in comments as well?

MS. ADAMS: We sent in pages of comments.

MS. GUNNING: I can't even believe we

didn't.

MS. ADAMS: I had a whole -- I had a whole

grid for -- of --

MS. GUNNING: Ramona and Bart and you-all,

when you-all stuff like that, will you

please see that Sheila gets that

information, so that we can get it out to

everybody? Because I hate to say it, but

it almost seems purposeful that they don't

get this stuff out.

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MR. SHANNON: Well --

MS. GUNNING: I mean, it's not --

MR. SHANNON: -- talked about it the last

time --

MS. JOHNSON: We're not --

MR. SHANNON: -- we were here.

MS. GUNNING: I don't guess I was here.

MR. SHANNON: The BHSO regs were. And the

last section of those regs list the time.

Now, I pointed out that the hearing was

going to be whenever it was and submit your

request by August 31st. Well, the hearing

was on August 26th. I said, that ain't

right, so -- but -- so it was posted then.

We talked about it at the meeting that it

was available and they were going to send

them out. And they did a conference

call --

MS. JOHNSON: They really didn't send them

out, though. They -- in their responses to

the TAC --

MR. SHANNON: Right.

MS. JOHNSON: -- they said that they sent

the regs by e-mail to providers. They

never did.

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MR. SHANNON: You know, I never saw them.

I went to the website. But it was clearly

posted --

MS. JOHNSON: We never got them and we got

them -- you were kind enough to send them

to us or we would have had to have done the

same thing.

MS. GUNNING: That would have been nice,

send them out.

MR. SHANNON: Yeah, it was discussed here.

They were on the website then.

MS. GUNNING: -- brought it up, so I guess

I didn't hear that part.

MR. BALDWIN: Any time there's a reg buried

all the way at the very bottom --

MS. JOHNSON: They're in.

MR. SHANNON: Above the rules.

MR. BALDWIN: Yeah. There's a due --

comments are due --

MS. JOHNSON: Yeah.

MR. BALDWIN: -- date and then a hearing.

MS. JOHNSON: Yeah.

MR. BALDWIN: A question on the hearing.

Did they -- did they respond to anything or

did they just --

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MS. JOHNSON: No, no. They had the

recorder there, the person who records, and

the person who was listening. And she

wasn't from Medicaid. She was from --

MR. SHANNON: Legal services.

MR. BALDWIN: I think the whole term

hearing is a little --

MR. SHANNON: Yeah, it's not.

MS. JOHNSON: And she said --

MR. SHANNON: Oral argument.

MS. JOHNSON: -- I am here to hear your

comments. I will not answer questions.

There will -- this is not a discussion.

MS. MUDD: What's the point?

MS. JOHNSON: Yeah.

MS. GUNNING: Well, to be heard.

MS. SCHUSTER: Well, all you're doing is

talking to a court reporter, so it gets

into the system, you know. And

occasionally -- and it's been a long time,

we used to get media over there sometimes

if we were going to get a big turnout of

people with the --

MR. SHANNON: The SEL --

MS. SCHUSTER: -- the SEL once upon a time,

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you know.

It's a good reminder to me, Kelly,

that when we talk about these regs in here,

that I need to send out just that piece

about what the timeline is and how you

submit those comments.

MS. GUNNING: Yeah, because I know DeBars

(phonetic) and I brought it up about the

psychiatrist.

MS. SCHUSTER: Yeah, but we talked about

it. I guess because we assumed that people

know that when there's a reg, there's

always --

MR. SHANNON: -- say the regs were at?

MS. SCHUSTER: -- there's always a written

comment period.

MS. GUNNING: Yeah.

MS. SCHUSTER: Sometimes a public hearing

and sometimes not.

MS. GUNNING: Somehow we just missed this

one.

MS. SCHUSTER: So --

PARTICIPANT: But that's even difficult to

find on their website --

MS. GUNNING: I'm just saying they don't

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make it easy --

MS. SCHUSTER: No, they don't make it easy.

MS. GUNNING: And so if we can help each

other in any way, that would be great.

MS. JOHNSON: They don't make it easy to

find.

MR. BALDWIN: Well, and the other piece is,

given our discussion earlier, you can't

assume anything unless you brought up --

MS. JOHNSON: No.

MR. BALDWIN: -- necessarily, so --

MR. SHANNON: No. I got -- I got a

comment --

MR. BALDWIN: Be more diligent about the

regs.

MR. SHANNON: It was not appropriate at

this time. What's does that mean?

MR. BALDWIN: Well, that just means through

the TAC or whatever --

MR. SHANNON: Yeah. But even the reg

comment, that's -- that's the response you

get back, right?

MR. BALDWIN: Yeah.

MS. GUNNING: I just -- it's hard to comb

through every single thing when you got 20

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programs going on.

MR. BALDWIN: Yeah.

MS. GUNNING: And so if we had a way to

find the needle in the haystack, just a

heads up would be nice, but...

MR. BALDWIN: Absolutely.

MS. GUNNING: I mean, we miss them

sometimes.

MS. JOHNSON: Excuse me. I don't want you

to miss them because we need your voices.

Somebody over on the other side of the

little wall there said something about not

being able to be a one and a two at the same

time or whatever.

MS. SCHUSTER: Yeah.

MS. JOHNSON: I actually got a response

from Ann -- what's Ann's last name?

MS. SCHUSTER: Holland?

MS. JOHNSON: Yes, from Ann Holland. She

responded when I first submitted my

comments that I copied them to her. And

she said that if we wanted to continue

providing services to people with

co-occurring substance use, that we could

get an AODE and we could be licensed as a

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BHSO 2 and a 1. So we could be licensed as

a one and a two. And with the AODE license

could provide -- continue to provide

co-occurring services. So she did say you

could be licensed in two different levels.

And, now, add did to that streamline

government and cut red tape and reduce

administrative burden.

MS. GUNNING: Does it change the --

MS. JOHNSON: No. It increases all of

that.

MS. GUNNING: -- reimbursement rate?

MS. JOHNSON: That was part of the issues

that I thought of when doing all of this,

is because a BHSO had to have an AODE, two

licenses to provide substance abuse

services and we thought this was

streamlining it. But I thought initially,

especially from the webinar, that when they

had providers, you had to go in and select

which kind of a BHSO you are, if you are

already a BHSO.

PARTICIPANT: Yeah.


MS. JOHNSON: It wasn't multiple choice,

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was it? I mean, you couldn't pick a Tier 1

and a Tier 2 and Tier 3, could you? You

could only pick one. And so that's where I

think a lot of the confusion has come in.

So now they're saying you can have --

MS. GUNNING: -- you can have multiple

licenses.

MS. SCHUSTER: Well, one person at DMS said

that.

MS. JOHNSON: That does nothing to

streamline what we thought they were

working to fix to begin with.

PARTICIPANT: No. It just makes it more

complicated.

MR. SHANNON: CMHCs had to have the CMHC

and AODE license. Then about four years

ago they said you don't need the AODE

license.

MS. SCHUSTER: Yeah.

MR. SHANNON: Then about two years ago they

said you need the AODE license.

MS. SCHUSTER: Yeah.

MR. SHANNON: And most of the centers kept

their AODE license just because, you know,

they had it. But, yeah, it was the same

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question, why do you have to do that?

PARTICIPANT: And then all the AODE regs

change.

MS. GUNNING: Yeah, they changed them and

didn't tell anyone.

MS. SCHUSTER: I did send comments from the

Mental Health Coalition at literally at

10:00 p.m. on the last day that they were

due, just simply saying, you know, you're

really hurting people with severe mental

illness. You're not allowing them to

continue to be treated with the BHSO where

they have been treated; 50 percent of the

people are going to have co-occurring. And

then talked about the irony of this

administration that's been pushing so hard

for people to get to work, to make it

impossible for people who are peer support

specialists to actually earn a livelihood.

So I'll send that out. I meant to make a

copy of that. It was last minute, but I'll

send that out.

I wonder if there's any kind of

recommendation that the BH TAC should make

about this issue. I mean, it's almost the

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only other thing that we've got available to

us. And I guess I'm wondering about a

recommendation that says, this is such an

important issue because of the potential

loss of services to people with severe

mental illness, 50 percent or more of whom

are going to have a co-occurring disorder to

get treatment from knowledgeable providers.

MS. GUNNING: Integrated treatment.

MS. SCHUSTER: Integrated treatment.

MS. GUNNING: Integrated is base treatment,

because --

MS. SCHUSTER: Evidence based.

MS. GUNNING: -- integrated is evidence

based.

MS. SCHUSTER: Yeah, evidence based.

PARTICIPANT: Well, and here's -- is there

an option of the Behavioral Health TAC

requesting that this be put on the next MAC

agenda and it be an agenda item where folks

could go to the table and --

PARTICIPANT: There you go.

PARTICIPANT: -- voice the concern since

the Commissioner would be in the room?

MR. SHANNON: Yeah. I also think, why

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don't we instead of recommend to DMS, we

recommend to the MAC that they request of

DMS. Because they say the MAC is -- they

answer to the MAC. So I think the same

strategy is run everything through the MAC

and let the chair of the MAC know that's

what we're doing. Because the MAC I think

will say it's a MAC issue. But if the MAC

goes back to DMS saying we need to have

this conversation, right?

PARTICIPANT: I think the implementation

date for the regs needs to be postponed.

MS. GUNNING: It was crazy.

PARTICIPANT: It needs to be suspended

because --

PARTICIPANT: It was July 1, wasn't it?

PARTICIPANT: It was July 1 --

MS. GUNNING: Yeah.

PARTICIPANT: -- got them.

MR. KELLY: And we got them on the 27th.

MS. SCHUSTER: Yeah, because these are

E-regs.

PARTICIPANT: The E-regs.

MS. SCHUSTER: They're in -- they're in

effect.

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PARTICIPANT: And so technically they're in

effect.

MR. SHANNON: They're in effect right now.

PARTICIPANT: And we've already gotten

notification from one MCO that they're

going to pay the posted peer group rate of

6.25.

MS. GUNNING: Yeah, we have -- we've heard

it.

PARTICIPANT: Yeah.

MS. GUNNING: You know, remember, we're not

a BHSO, but our people have to rely on

those services.


MS. GUNNING: We have never become a BHSO,

but I'm very concerned about what's

happening in this realm because all of our

individuals are impacted by it.

MS. SCHUSTER: So what's our

recommendation? I'm a little bit confused

about what you want to do? Steve, when

you're saying recommend to the --

MR. SHANNON: Well, I think we need that

recommendation. But going forward, based

on the Commissioner's response, we report

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to the MAC. So do we make a recommendation

to the MAC that they make a request to DMS.

So on all our recommendations, right, every

recommendation that we make, we recommend

that DMS communicate to the relevant TAC or

MAC, right? And we recommend that the MAC

request of DMS to communicate the relevant.

Because our relationship is with the MAC.

So can we get the MAC to make those

requests? I think the next meeting the

requests to the MAC is the BHSO changes are

on the agenda.

MS. MUDD: So the MAC will request the

response from CMS?

MR. SHANNON: Do we get a different

response. Because the Commissioner said we

report to the TAC, right?

PARTICIPANT: Correct.

PARTICIPANT: You'll have to clarify --

MR. SHANNON: Advisory capacity to the

council.


MR. SHANNON: So we're advising the council

to make a request of DMS. Because as it

stands now, they just say the MAC is who

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your relationship is with; we want to have

the relationship -- we want to get answers.

MS. SCHUSTER: Yeah, but the problem is

we're two more months down the road.

MR. SHANNON: I know. But next month we

request BHSO be on the agenda.

MS. GUNNING: And, you know, to clarify

what Steve heard about the units and is it

per unit or per head? That's a very

confusing thing.

PARTICIPANT: That's CMS issues --

MS. GUNNING: It's very important that we

know.

MR. SHANNON: One recommendation is -- I

would make, is at the next MAC meeting at

the end of September that the BHSO regs are

on the agenda and public comments are

accepted on those BHSO regs.

MR. BALDWIN: But what you're thinking,

Sheila, is the MAC --

MS. SCHUSTER: There's no way to make that

to the MAC --

MR. BALDWIN: The MAC wouldn't do

anything --

MS. SCHUSTER: -- in time for their -- for

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their -- for us to get on the agenda for

September. That's my --

MR. BALDWIN: They wouldn't --

MS. SCHUSTER: -- that's my concern.

MR. BALDWIN: They wouldn't act on it until

they met again and then you're two

months --

MS. SCHUSTER: And then you're two months

down.

MR. SHANNON: Well, then we make -- this

request we make to DMS as we normally do.

They're going to ignore it; right?


MR. SHANNON: I mean, there's not a choice.

But going forward, I think every

recommendation runs through the MAC to DMS.

It slows down the process, but they don't

respond now; right? Because this one I

think we've got to see if we can get on the

agenda.

MS. SCHUSTER: For September.

PARTICIPANT: Are we more than two weeks

away from the MAC meeting, is that why we

can't get on --

MR. SHANNON: No.

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PARTICIPANT: -- their agenda?

MR. SHANNON: No.

MS. SCHUSTER: No. We're still -- they're

supposed to turn in their agenda two weeks

in advance, and so they -- they're meeting

September 23rd.

MR. SHANNON: 26th.

MS. SCHUSTER: Or 26.

MR. SHANNON: 26th.

MS. SCHUSTER: So we're okay. I just have

never gone directly to the MAC and

requested that an -- that an item be put on

there.

PARTICIPANT: But I think it's because you

aren't part of the MAC. Because we're

hearing dental issues all the time, because

we've got a dental rep right here on the

MAC.

MS. SCHUSTER: Yeah.

MR. SHANNON: Yeah, we don't have a person

on the MAC.

PARTICIPANT: -- hearing ophthalmology

because --

MS. SCHUSTER: Yeah.

PARTICIPANT: -- there's an

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ophthalmologist. We're hearing nursing

homes --

MS. SCHUSTER: I bet the --

PARTICIPANT: -- so I think it's because

you're not part of the MAC --

MR. SHANNON: I think --

PARTICIPANT: -- but that's why our --

that's what we're supposed to do, I

think --

MS. SCHUSTER: Yeah. Yeah.

PARTICIPANT: -- according to their

responses.

MR. SHANNON: That's the vehicle.

MS. SCHUSTER: All right. So that's a good

point. I mean, I don't -- I certainly

don't mind asking her and telling her that

this is really critical because these regs

are in effect.

MS. GUNNING: And especially the psychiatry

or the specialties in SUD and to be a

provider you have to have that designation

as an addictionologist.

MS. SCHUSTER: Yeah. I mean, there's so

many problems with these -- with these

regs. But do we in addition want to make

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any specific recommendation? I guess I'd

like to have something on record in case --

MR. SHANNON: Yeah. No. Yeah, yeah.

MS. SCHUSTER: I can't do it or --

PARTICIPANT: You had very clear

recommendations in what you submitted.

MS. GUNNING: Yeah, you did.

MS. SCHUSTER: Yeah.

PARTICIPANT: And what we're asking you,

please do this.

MS. SCHUSTER: Okay.

MR. SHANNON: Yeah. And my concern is DMS

is going to say we received those comments,

thank you.

MS. SCHUSTER: Yeah, we've already received

them.

PARTICIPANT: We've already received them.

MR. SHANNON: That's why the MAC says, I

want to hear this issue.

MS. SCHUSTER: Okay. I got you. All

right. Can we get a motion that I will

write up those specific recommendations

that we have all talked about and add those

in our recommendations?

MR. SHANNON: I move that, yes.

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MS. SCHUSTER: How's that for a vague

motion? You move that, Steve? Mike, Val?

MR. BARRY: I'll second -- I'll second

that --

MS. SCHUSTER: All right.

MR. BARRY: -- whatever that is.

MS. SCHUSTER: All right. All in favor?

PARTICIPANT: Aye.

MR. BARRY: Albeit.

MS. SCHUSTER: Albeit.

MR. SHANNON: Do we have a second motion

that we will request of the MAC to put the

BHSO regulation on the agenda for public

discussion on September 26?

MS. MUDD: I'll move it.

MS. SCHUSTER: Yeah. Val will move that.

Second?

MR. BARRY: Second.

MS. SCHUSTER: Second. All in favor.

COMMITTEE MEMBERS: Aye.

MS. SCHUSTER: Okay. All right. Thank you

very much.

MR. BALDWIN: Before we -- before we move

off that -- those regs, can I just comment

on a couple of things?

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MS. SCHUSTER: Yeah.

MR. BALDWIN: Process-wise -- and I think

it's good to get this on the agenda sooner

rather than later if we can, because

they're E-regs.

MS. SCHUSTER: I know. July 1 --

MR. BALDWIN: They're also going -- but

they're also going through the process.

But after we make all these comments,

they're -- the Cabinet is required to do a

Statement of Consideration within 30 days

and they can request the 30-day -- another

30-day delay.

PARTICIPANT: And they've already said it's

likely they won't be out until October

because there's so many --

MR. BALDWIN: So many, yeah.

PARTICIPANT: -- comments they have to

respond to.

MR. BALDWIN: So it will probably be longer

than that. And then it goes to the

administrative regulation review

subcommittee --


MR. BALDWIN: -- to review, which it

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doesn't have to say -- this is their right.

It doesn't have -- they don't necessarily

approve it.

MR. SHANNON: No.

MR. BALDWIN: There's been some legislation

in past years worked on that, but none of

those bills ever passed. So there is an

opportunity -- point being, your point,

there is an opportunity for a public

hearing on the regulation --

MS. SCHUSTER: Yeah.

MR. BALDWIN: -- at that committee,

whenever it takes place, which sounds like

it will probably be November.

MR. SHANNON: Yeah, I think November.

MR. BALDWIN: November. And then after

that it goes to the subject matter

committee, which will be held at Department

of Family Services on this one. There's

opportunity to comment. Although a reg

rarely gets that far to the health and

welfare. But sometimes the legislators, on

an administrative reg, will tell the

Cabinet, clearly, you don't have this right

yet, go back and work on this. We'll --

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MS. SCHUSTER: Yeah.

MR. BALDWIN: -- we'll defer this reg

another month and come back. So there's --

I'm just pointing out that there are other

steps in the process that if they -- if

they just come back with a statement of

consideration and say thanks, for your

input, we're keeping it as is, you know --

MS. SCHUSTER: Yeah, I think --

MR. BALDWIN: -- there's other venues.

MS. SCHUSTER: -- we flood KARRS members

with exactly the same.

MS. MUDD: If we're supposed to go to --

MR. BALDWIN: And that is more of a -- I'm

sorry. That is more of a hearing where the

legislators can ask questions.

MS. MUDD: Right, right.

MR. SHANNON: Yeah, there's a discussion.

MR. BALDWIN: A discussion --

MS. MUDD: And we can talk to legislators

ahead of time --

MR. BALDWIN: Yes.

MS. GUNNING: Yes.

MS. MUDD: -- and let them know what our

issues are.

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MS. GUNNING: Yes.

PARTICIPANT: In fact, that was my next

step -- my next step of the strategy. I

mean, we've gone -- taken these steps and

that was going to be my next step, was

to --

MR. BALDWIN: Yeah.

PARTICIPANT: -- ask for a meeting with --

of course, my legislature is Mary Lou

Marzian, so it's not -- I'm preaching to

the choir --

MR. SHANNON: And I think she's on -- she's

on the committee.

MS. GUNNING: She's on that committee.

MR. SHANNON: That's who you got to focus

on, the committee members.

PARTICIPANT: One of the things you want to

do is, when you get the Statement in

Consideration is to see how the Cabinet

responded and if they made a favorable

change --

PARTICIPANT: They may make some changes.

PARTICIPANT: -- usually before you go to

ARRS or legislators. That's just usual.

PARTICIPANT: One question I had, Sheila,

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is can they withdraw an E-reg? Because I

was just wondering if there's merit in

asking for them to withdraw the E-reg and

back up a bit.

PARTICIPANT: Yeah, that would be great.

PARTICIPANT: Because it's thrown the whole

everything in turmoil.

PARTICIPANT: Yeah, they had no idea what

they were doing.

MS. SCHUSTER: Yeah.

PARTICIPANT: I mean, and even when you

write a reg, if you're going to have it be

effective the day you file it because it's

an E-reg, at least provide for some as of

October 1st -- you know, delay the

implementation so people can come up to par

with the new requirements, because --

PARTICIPANT: They're not really

licensed --

PARTICIPANT: We're not in accordance with

the reg right now.

PARTICIPANT: None of us. No one. Because

they're -- all of their payments will be

denied --

MR. SHANNON: Yeah.

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PARTICIPANT: -- because they're not

appropriately licensed.

MR. BALDWIN: Yeah, there's one -- there's

some E-regs you can do emergency regs --

licensure like you said -- but everybody

that had that license is out of compliance

as soon as -- well, I guess you can

withdraw an E-reg.

PARTICIPANT: I was all upset about the

webinar and not knowing about the webinar.

Because if people didn't know about it,

then they didn't know to get online and

they had to be online and registered before

July 1st. And now it's -- I'm not sure if

they all registered as one, two and three

or just one, three. I don't even know now

that I've seen the regs and read through

them.

MS. SCHUSTER: All right. Do we want to

ask for the E-reg to be withdrawn?

PARTICIPANT: Yeah, all of them.

MS. SCHUSTER: Okay.

MR. BALDWIN: Let the ordinary regs go

through the process.

MS. MUDD: Including the OIG reg.

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MS. GUNNING: Yeah, the OIG one was

confusing, too.

MS. MUDD: I just thought of that one at

the last minute.

MS. SCHUSTER: Well, Valerie --

MS. GUNNING: But that would put you out of

compliance with KARP, right?

PARTICIPANT: No, no. That was is -- that

was in the --

MS. GUNNING: That was the other one. I'm

sorry. That was a screening assessment

one.

MR. BALDWIN: E-regs, they're just good for

180 days?

MR. SHANNON: Yeah, they're just good --

MS. SCHUSTER: Yeah.

MR. SHANNON: -- the end of the year. The

other ones have to be implemented by the

end of the year.

MS. SCHUSTER: Yeah.

PARTICIPANT: Yeah, you need to make sure

that if you're going to request Chapter 15

regs be withdrawn, that the OIG one be

withdrawn.

PARTICIPANT: Was it an E-reg or an

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ordinary?

PARTICIPANT: It was an E-reg also, I

think.

MS. SCHUSTER: All right. Okay. On to the

next thing.

MS. MUDD: I have a -- I have a question.

MS. SCHUSTER: Oh, yeah.

MS. MUDD: If we're supposed to be sending

our recommendations to the MAC and not to

DMS, why is DMS responding, period? I

mean, you understand what I'm saying?

MS. SCHUSTER: Yes.

MS. MUDD: I mean, why don't we get a

response from --

PARTICIPANT: Because we do go through the

MAC.

MS. MUDD: -- response from the chair?

MS. SCHUSTER: Because we are -- we are

sending our recommendations to DMS, but the

only way we can get them there is through

the MAC.

MR. CALLEBS: And they respond to the MAC.

MS. SCHUSTER: And they respond -- well,

actually, no, they don't --

MS. MUDD: They responded to us.

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MS. SCHUSTER: -- which is interesting,

they responded to us.

MS. MUDD: That's why I'm confused.

MR. CALLEBS: Well, this responds to the

MAC. Specifically, it's the number one

"to", and then underneath. It is a

response to the MAC. The MAC sends the

recommendations up to Medicaid. And then

Medicaid -- if they get a written

recommendation from the MAC, it's my

understanding they must respond in writing

to the MAC, which they did, and also the

TAC, but primarily to the MAC, I think, as

a courtesy to the TAC.

MS. SCHUSTER: Yeah, right. Because --

MR. CALLEBS: So they are consistent.

MS. SCHUSTER: -- their response goes to

the MAC and to our TAC.

MR. CALLEBS: So they have responded

according to the designated process, but,

again, good point, not much a response in

some cases.

MS. SCHUSTER: Yeah.

MR. CALLEBS: But they would deem this as

being in compliance with their

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responsibilities, because they responded

appropriately to the MAC.

MS. SCHUSTER: Exactly.

Fareesh, I'm delighted that you're

here, because you raised a question about

formulary changes. Do you want to talk

about what your concerns were?

DR. KANGA: I didn't know that I would be

able to make it today, so --

MS. SCHUSTER: I have your -- I have your

e-mail if you want to.

DR. KANGA: I don't know what I did this

morning, so...

MS. SCHUSTER: Now speak up so everybody

can hear you.

DR. KANGA: Oh, okay. So what we're

running into is --

MS. SCHUSTER: You want to introduce

yourself since you weren't here for

introductions.

DR. KANGA: It's getting worse and worse.

This is the Tuesday that turns into a

Monday.

I am -- I'm Fareesh Kanga. I'm a

psychiatrist in Lexington. I work at

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HealthFirst and the University of Kentucky.

And I -- and I'm also with NAMI Lexington.

And I have been having issues recently, me

and some of the people that I supervise,

because things that are on formulary, then

go off formulary and we're not really

notified, or, for example, apparently

Vyvanse was taken off the preferred list of

medications. And so it was preferred, so

they were asking us to use it. Then they

took it off, which is fine. But then they

wanted us to use two other medications

before we could go back to the Vyvanse, even

with a prior authorization. The child had

been on it for like years and they wouldn't

even give a seven-day refill as we try to

sort of figure it out, like an emergency

fill. So like -- and this is right at the

start of school. So then kids go without

medication right at the start of school. I

mean, it's like -- for those of you have

ever watched a kid tank at school because of

medication and the lack thereof, it's really

heart breaking. I mean, these are like

kids, but, you know.

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And then my adult nurse practitioner

said that Invega Trinza, the long-acting

injectable, had been removed and there was

no notification of that. And they were told

that they just want you to use the oral

medication like Invega oral. I mean, it's

not even -- does not even compare. And for

those of you who see patients on long-acting

injectables, that's life-changing

medication. Those are people going back to

work, getting their lives back, so on and so

forth. So those were my -- those were the

two that we came up with in August that were

just --

MS. SCHUSTER: So I asked the MCOs to

provide us with information about the

formulary changes. And why don't we start

over there with Passport.

MS. McKUNE: We have had two changes during

this time period. So one was a formulary

change in May in which four members who

would be new to being prescribed Vyvanse it

became non-formulary. For those that were

existing, already on, it was continuing

treatment, they were grandfathered. And

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then we have added a new to market drug,

the Bravado, in May.

MS. SCHUSTER: So I think, Liz, that back

to Kanga's experiences that those patients

were not being grandfathered, is that

your --

PARTICIPANT: Is there a time frame on

grandfathering?

MS. McKUNE: If they were continued in --

if they were continuing in treatment, if

they had been prescribed right before then.

If there was a gap in treatment, they would

have to go through a process, but if it was

continuing --

DR. KANGA: And those changes don't affect

grandfathering, right? I mean, they

shouldn't -- doesn't make sense. But one

of the other things we do, over the summer

I'll try to lower doses of medication

because the kid isn't in school anymore.

And sometimes we'll even go off medication,

if the kid can handle it, and we'll restart

medication end of summer. And so if that's

what's being called gap in treatment, we

will still have appointments and I'll check

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in on them and so on and so forth. If

they're off medication and they go back on

it after a month or two, that's a good

thing to do especially children gaining

weight or...

MS. McKUNE: Our pharmacist isn't here, so

I don't -- I don't know the answer to that.

But we do have an appeal process and I

think you could easily make that argument

and it sounds -- you know, so we're

continuing the care, I would think it would

be supported. I don't know for sure,

but...

DR. KANGA: Well, I mean, I wrote that -- I

wrote her after we had done the prior

authorizations. We had done all of that.

They weren't even letting us have anything.

So this child is without medication. We

can see them -- I mean --

PARTICIPANT: Without any medication?

DR. KANGA: Well, I mean, we can write it,

but we want to see the kid before we just

start him blindly on a new medication. You

know what I -- that's how we try to do it.

MS. SCHUSTER: So Passport changed Vyvanse,

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but only for new patients essentially?

MS. McKUNE: Yes.

MS. SCHUSTER: You're grandfathering the

other ones?

MS. McKUNE: Yes.

MS. SCHUSTER: There should be some

mechanism if a kid is titrated off or has a

drug holiday, or whatever we want to call

it in the summer. As long as the child is

still in treatment, they ought to be able

to get back on the Vyvanse.

MS. McKUNE: Right. There's an appeal

process.

MS. SCHUSTER: Okay.

MS. McKUNE: And the spirit and intent is

to continue children. It's not starting

brand-new medications that you would start

with Vyvanse.

DR. KANGA: This is not new. This is not a

start from scratch.

MS. SCHUSTER: Okay. So, obviously, there

is some slippage here. So what do you

suggest that Dr. Kanga do?

MS. McKUNE: I can give you my card at the

end and we can reach out to our Director of

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Pharmacy.

DR. KANGA: Okay. That sounds good. Thank

you.

MS. SCHUSTER: All right. Abner, did you

have any questions about Vyvanse --

DR. RAYAPATI: No.

MS. SCHUSTER: -- and that situation?

Let's see. Who else do we have MCO

wise? Aetna?

MR. JOHNSON: Yes.

MS. SCHUSTER: Yes.

MR. JOHNSON: So our pharmacist did provide

us a list of changes that -- that have

occurred since 2019 with the formulary.

And she also advised that there's access to

that on our website as well to look at

those changes. And I have a handout for

anybody that wants to know what those

changes are. And she actually put in

parenthesis what was done, whether it was

removed, if there was an age limit

requirement change or anything like that.

So does anybody want a copy? I can pass

them down.

MS. SCHUSTER: Yeah, give -- give Dr. Kanga

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one for sure.

MR. JOHNSON: Okay.

MS. SCHUSTER: And Dr. Rayapati over here

would be great.

Do you want one, Marc? Marc from

Pathways?

MR. KELLY: I got one.

MS. SCHUSTER: She sent me one. Yeah.

Thank you.

Anybody else? So this is a fairly

long list. It is helpful because it gives

the time frame and it talks about what the

changes were, whether they were, you know,

by age, by dosage or whatever. I will

also -- because I think I have this

electronically.

MR. JOHNSON: Uh-huh (affirmative).

MS. SCHUSTER: So if anybody needs it, if

anybody else needs -- Marc, do you want

one?

Okay. Thank you very much for that.

MR. JOHNSON: No problem.

MS. SCHUSTER: Who else do we have?

PARTICIPANT: Anthem.

MS. SCHUSTER: Anthem. So what's your

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story, Anthem?

MR. RUDD: So my name is Andrew Rudd. I'm

the Pharmacy Director for Anthem. So I

wanted to just talk briefly. You should be

getting -- Sheila, you should be getting a

update, a printout like what Aetna

provided, that breaks it down per quarter,

just kind of a high level. We had six

quantity limit changes. Four of those were

updates to existing limits; two were new

and those were because they were new drugs.

Quantity limits are within the dosing limit

of the package label, so they're just not

indiscriminately determined. There were

six PA changes. Four of those were updates

and then two were -- two new-to-market

drugs, one of those being Spravato. And

then the other was Evekeo VT, was added PA.

Basically, it was looking at diagnosis of

ADHD and then individual of six years of

age or old other, which is verbatim out of

the package label.

There were three step therapy updates,

and it was basically adding new drugs within

that class to those updates. And that

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information is available on the provider

portal as well.

MS. SCHUSTER: And then you're going to

send me that?

MR. RUDD: Yes, ma'am.

MS. SCHUSTER: Okay. Thank you.

And CareSource?

MR. VENNARI: Humana CareSource, yeah. My

name is Joe Vennari, Pharmacy Director. We

had only two changes. The Spravato, the

same as Anthem. We put PA on that for the

new drug. And age limit, it increased to

18 for Clozapine. That's it. And I can

send you those two changes.

MS. SCHUSTER: Okay. What about this

change in the Invega Trinza for the

long-acting injectable to a change to

requiring or requesting the oral medication

instead?

MR. VENNARI: Are you talking about Humana

CareSource specifically here?

MS. SCHUSTER: That's what you had,

Fareesh? You thought it was Humana

CareSource? Does that not sound familiar?

MR. VENNARI: No. I can take a look at

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that.

DR. KANGA: That's an adult issue, so it's

not something I have seen.

MS. SCHUSTER: Okay. Maybe you could give

Dr. Kanga your contact information; would

that be all right?

MR. VENNARI: That would be fine.

MS. SCHUSTER: Because she had that

question.

MR. SHANNON: But did any of the others

have that issue, because we -- maybe it's a

WellCare issue.

MS. SCHUSTER: Nobody else had changed --

none of the other MCOs changed the Invega

Trinza? Yeah, I wonder. And WellCare is

not here. So let's find out, but let's go

on -- why don't you go on and get -- before

you leave today.

DR. KANGA: I can find --

MS. SCHUSTER: Okay. And I'll get in touch

with the WellCare folks and see what we can

find out.

DR. KANGA: -- look into it.

MS. GUNNING: Sheila?

MS. SCHUSTER: Yeah.

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MS. GUNNING: I think this is a good

opportunity to reiterate how their P&T

committees work. And, I mean, when I look

over this list from Aetna, it's a lot of

drugs, it's a lot of changes, you know, two

and a half pages.

MS. SCHUSTER: Over the course of nine

months --

MS. GUNNING: Yeah.

MS. SCHUSTER: -- or something.

MS. GUNNING: But, I mean, still we have no

input really into that much at all.

MS. SCHUSTER: And is the State P&T

Committee still meeting?

MR. SHANNON: Yes.

MS. SCHUSTER: It is?

MR. SHANNON: Yeah. I mean, I see it on

the agenda, so...

MS. SCHUSTER: Okay.

MR. SHANNON: Yeah, we've made comments

repeatedly that --

MS. GUNNING: Yeah, I know.

MR. SHANNON: -- they ought to review. The

state one ought to review, just review. It

is a forum we can all go to, but that's

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never gone anywhere.

MS. MUDD: I mean, we've got -- we've got

lithium on here. Changes for lithium?

That seems a little crazy to me. I mean,

some of the other ones, you know, that I

try to keep up on the generic forms, but

lithium? Really?

MS. GUNNING: Well, the thing is, you know,

this -- this can all happen, once again, in

this, you know, vagueness of a black hole

and nobody has any way to counter it. In

the old days if we knew that they were

going to be taking a long-acting injectable

out of circulation or not allow it or

whatever without a bunch of hoops, we would

be up there raising cane. And, I mean,

long-acting injectables -- our state and

our department and our Cabinet keep saying

they want state of the art. They want --

PARTICIPANT: Or that it works, it works.

MS. GUNNING: -- to save money. They want

to save lives. They want people working.

But they're taking away everything that we

have that's providing that.

MR. KELLY: Well, we're talking about best

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practices, once again.

MS. GUNNING: Again.

MR. KELLY: Like we need regulations and

formularies that reflect best practices.

MS. GUNNING: That support what they talk

about.

MR. KELLY: That's what we need.

MS. GUNNING: Their actions don't match

their words.

MS. JOHNSON: Medicaid's actions don't

match.

MS. SCHUSTER: Well, we have --

MS. GUNNING: Medicaid's actions don't

match behavioral health words, just like

Ramona said. So, once again, we're like

kind of all this stuff happens in the cloak

of darkness. And then even prescribing MDs

don't find out until they go to do it.

DR. KANGA: That's a lot of our time.

That's a lot of my nurse's time, too.

MS. GUNNING: Talk about that a little bit

more, Fareesh, please? Just about how much

time they -- they think that changing one

or two of these drugs is no big deal, but

tell them the reality.

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DR. KANGA: Hours. Those PAs are hours and

hours. I mean, I don't -- I'm not

exaggerating. I have myself -- when my

nurse is out, I do my own PAs. And we're

talking two and a half hours. We're

talking a process in one day; we're talking

a process that can continue over two weeks,

if you have to get into appeals. And I'm

in clinic. I mean, I've got other people

to see and I'm -- you know, I'm backed up

and I'm on hold and I just can't get

through. Or you're -- you know, you're

told A person tells you X, and then B tells

you Y. And, I mean, it's just you go

through 15 different people before you get

anywhere. It's hard -- I mean, it sounds

like just submit this paperwork. It is not

that simple.

MS. SCHUSTER: It's not that easy.

MS. GUNNING: And this is 51 changes. Now,

you know, again, I'd like to go back to

even not knowing about where the regs are

buried and where the hearings are buried in

the regs and all that kind of stuff. All

of us are busy doing other things besides

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just combing the regs and the e-mails and

looking for when a webinar is going to be

or when a hearing is going to be or when to

file your comments by. I mean, I'm not

sitting there. I'm out in the community.

I'm not sitting at a desk. I don't have an

administrative assistant that sits there

and combs through this stuff for me saying,

oh, you better respond to this.

MS. MUDD: I'm a little -- there's -- I

mean, the -- Clozapine is limited as it is.

I think that's interesting that Clozapine

is on this list. That there is a quantity

level limit when -- I mean, you know,

Clozapine, there's a -- there's a quantity

limit on it already.

DR. KANGA: And there's -- I mean,

Clozapine, you're monitoring it pretty

closely, not just willy-nilly throwing

Clozapine --

MS. GUNNING: I mean, we don't want anyone

to get a granular psychosis, so we're not

going to have them out there taking pill

bottles full. But 51 changes. Oh, by the

way, here's our 51 changes.

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MR. JOHNSON: I know that -- I understand

the conversation and frustration there. I

just want to -- I did have the opportunity

to be on a conference call with the list,

since we did provide it. I just want to

say the changes that occurred with that

were based on best practices and based on a

lot of meetings, I guess --

MS. GUNNING: But meetings with who?

MR. JOHNSON: Meetings with people who are

on like -- they have a committee. And I

cannot think of the name of it, but I can

get that to you.

MS. GUNNING: P&T Committee?

MR. JOHNSON: That they sat with and -- and

they do the recommendations from the FDA,

VA those type of guidelines that are coming

down for those changes. And any -- our

pharmacists let me know that any negative

impact that it could have to a patient or

member regarding a drug change, that

they're giving 30-day notice to the

provider and to the member before that

change becomes effective.

MS. GUNNING: Did you know about all this?

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DR. KANGA: No.

MS. GUNNING: What? No?

DR. KANGA: No.

MS. SCHUSTER: I think the problem is that

there was a time when we had a single

formulary that was the Medicaid formulary.

And we had a P&T Committee and we worked

very hard. In fact, passed legislation to

put an additional psychiatrist on that. So

we had two psychiatrists, one from the

community and one from one of the

universities, because we wanted to be sure

that we had input. And we used to storm

those meetings. I mean, they -- you know,

you had to register weeks in advance and

all this stuff. But we used to be there

and speaking up about the impact of some of

these changes. And it's all changed

because every MCO has its own formulary.

And we have recommended, I don't know

how many times, that Medicaid go back to a

single state formulary, which all of you-all

MCOs would be fighting, jumping up and down

and saying, no, you don't want to do that.

The fall-back recommendation, which we also

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made a number of times, was that the

Medicaid P&T Committee should review these

changes that were being made like the

changes that we had asked for here, and have

an opportunity at a public -- at a more

public hearing to post those changes and get

input from practicing psychiatrists who are

in the field, psychiatric nurse

practitioners who are seeing patients --

MS. GUNNING: Patients --

MS. SCHUSTER: -- every day.

MS. GUNNING: -- patients and their

families.

MS. SCHUSTER: Patients and their families

and -- and advocates.

MS. MUDD: I mean, we've had this problem

since day one when the -- the MCOs walked

in the door. You know, I mean, they told

us we're going to grandfather people in,

you know, it's going to go fine. And, bam,

it's just been a mess.

MS. SCHUSTER: Yeah. I mean, I can think

back to the summer of 2011 when we had a --

we were in the biggest room you could have

up here. It was standing room only. And

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we had the three MCOs up here. And they

swore to us, on a Bible, that people would

get their medications. They would get

grandfathered in on their medications; they

would never be taken off those medications.

MS. GUNNING: And we'd have -- and we'd

have representation.

MS. SCHUSTER: Yeah.

MS. MUDD: And it was just a flat-out lie.

MR. SHANNON: We didn't know what

grandfathered meant.

MS. GUNNING: I do remember that.

MS. SCHUSTER: Yes, yes, that's right, we

didn't know what grandfathered meant.

Do we want to go back and make a

recommendation again just for the hell of

it, just to not let this --

MS. GUNNING: Again, I think using the

process that Steve outlined, get it on the

MAC and make it to the MAC and --

MS. SCHUSTER: And say that we -- that we

request that the --

MR. SHANNON: Yeah. It may slow it down,

but we're not getting a response from

Medicaid.

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MS. GUNNING: Yeah.

MS. SCHUSTER: That the Medicaid P&T

Committee would review, at least annually,

if not every six months, changes in the

formulary for the psychotropic meds.

MS. GUNNING: Well, especially when there's

going to be so many.

MS. SCHUSTER: Okay. Somebody want to make

that recommendation?

MR. SHANNON: I'll so move.


MS. MUDD: Second.

MS. SCHUSTER: All right. All in favor

signify by saying aye.


MS. SCHUSTER: Okay. Thank you for

bringing up those issues, Fareesh.

DR. KANGA: Thank you all for getting to

it.

MS. SCHUSTER: Because if we don't hear

from the practitioners -- and I know you

don't have enough time to send e-mails, but

I'm trying to take them -- trying to take

them and go to the next level with them.

DR. KANGA: I mean, I'm glad -- anything to

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make a day in the life of all of us doing

this work easier.

MS. SCHUSTER: So that people get what they

need when they need it without a lot of

hassle.

DR. KANGA: Right. Or I'll just stop

getting Board certified.

MS. SCHUSTER: Well, don't do that.

DR. KANGA: Well, apparently, it doesn't

matter.

MS. SCHUSTER: So, Kathy, this next item is

yours, and DMS did not reply to it. Kathy

had asked about the timeline for

implementing single credentialing entity,

which was House Bill 69 in 2018 and House

Bill -- Senate Bill 110. Do you have any

updated information?

MS. ADAMS: I've been trying for months.

I've sent it to the DMS issues. I'm a rule

follower, except when it comes to driving

the speed limit, maybe.

MS. SCHUSTER: Let's not -- you're on the

court record here. You know, be careful.

You didn't get her name, right? (Laughter)

MS. ADAMS: So, yeah, and no response, no

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response. I've sent another one. I'll get

a response back that says, oh, we'll

research this. And it's like this is a big

Medicaid -- should be a big Medicaid issue.

MS. SCHUSTER: Well, this ought to be a big

MAC issue, because it's --

MS. ADAMS: Why can't you tell us --

MS. SCHUSTER: -- it's every, professional;

right?

MS. ADAMS: Yeah. And so, again, sent

another one just -- I think right before I

sent it to you, I sent another one and

still no response, no update.

MS. SCHUSTER: All right. Yeah. Bart?

MR. BALDWIN: I thought it was going to be

July 1 next year when everything else gets

rolled in, the new contracts. But maybe I

just -- maybe I just assumed that. But if

you're not getting a response --

MR. SHANNON: She addressed this in the

committee last week.

MR. BALDWIN: I mean, that was months ago.

It could change.

MS. ADAMS: But that was a verbal thing --

MR. SHANNON: Yeah, I know, I know.

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MS. ADAMS: -- that she said at one of the

hearings. I believe what she said was

that, I've got my chief somebody --

MR. SHANNON: Yeah, that's right. Yeah.

MS. ADAMS: -- solely assigned to this

issue and it's taking much longer than we

thought, and we're going to do an RFP for

the single credentialing agency.

MR. SHANNON: That was...

MS. ADAMS: Okay. So what's the timeline?


MS. ADAMS: When -- when can we expect this

to happen?

MR. SHANNON: Yeah, the Chief of Staff is

going to address this issue, Medicaid Chief

of Staff. That's her task.

MS. SCHUSTER: Who is that?

MR. SHANNON: I wrote her name down

somewhere.

MR. BALDWIN: Yeah.

MR. SHANNON: She's recently hired.

MR. BALDWIN: Recently -- yeah, I seen her

in a committee hearing. I didn't know her

before.

MS. SCHUSTER: Do we want to ask the MAC to

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put that on their agenda? Because that's

actually a MAC issue.

MS. GUNNING: I think it's a MAC issue.

MS. SCHUSTER: It really is.

MS. GUNNING: It's a MAC issue.

MS. SCHUSTER: All right. Valerie, you

want to make that motion?

MS. MUDD: All right.

MS. SCHUSTER: Second?

MR. SHANNON: Second.

MS. SCHUSTER: Steve. All in favor signify

by saying aye.


MS. SCHUSTER: All right. Boy, Beth's

going to be really excited when I call her

with all these things.

MR. BALDWIN: Going to take over their

agenda.

MS. SCHUSTER: Yeah. Update on Kentucky

Health. October 11th is the day of the

oral arguments in front of The Court of

Appeals, the Federal Court of Appeals on

the Medicaid waiver. So that also is the

day of the Kentucky Voices for Health

annual meeting, which you-all are invited

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to, which will be in Lexington. It's going

to be a good program. But we will have

eyes and ears in D.C. at that hearing, and

I'm sure we'll be getting little text

updates and so forth.

MR. SHANNON: Live streaming.

MS. SCHUSTER: Live streaming, yeah.

PARTICIPANT: When did you -- what was the

date, Sheila?

MS. SCHUSTER: October 11th, so Friday.

And I think they start at either 9:00 or

9:30.

In your handout materials, you know,

the KI-HIPP is still going forward. That's

the program where Medicaid folks are

encouraged right now to take advantage of

their employers' insurance. And they've

sent letters out to about 35,000 people on

Medicaid, and another group -- another group

of 35,000 letters is supposed to go out in

September. Kentucky Voices for Health,

Kentucky Center for Economic Policy, and

Kentucky Equal Justice Center have done an

analysis of KI-HIPP, which is this front and

back, which really should have you -- have

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people pause about getting into that

program.

As far as we can tell, people are

going to have to pay the premium themselves

and then get reimbursed, which is certainly

a problem for most of our folks on Medicaid.

Also, if they see a provider who is not a

Medicaid provider, even though they are

covered by the employer's insurance, they

are responsible for all the cost sharing.

And those copays and deductibles and so

forth are going to be a whole lot higher

than they are on the Medicaid program. We

also are not sure what happens if the person

loses their Medicaid coverage, whether they

stay on the employer's insurance or not. So

there's a whole transition piece here that

we have concerns about. So we're

suggesting -- and I don't know if any of you

had -- Kelly, have you had people, or Val,

come with these letters and ask you about

them?

MS. GUNNING: No.

MS. SCHUSTER: Okay. So I have --

MS. GUNNING: That's scary.

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MS. SCHUSTER: Yeah, I mean, they're --

MS. GUNNING: They probably don't even look

at them.

MS. SCHUSTER: Well, another 35,000 letters

are going to go out. So I just suggest

that you really have people be careful.

MS. GUNNING: Because usually when they get

them, if they think it's something to do

with terminating their benefits, they'll

bring it to us.

MS. SCHUSTER: Yeah.

MS. GUNNING: I haven't had that one, have

you?

MS. SCHUSTER: It's not mandatory yet.

There is some question about whether

they're going to try to make it mandatory.

Right now it's voluntary. And I think they

said 179 people have signed up, so,

obviously, there's not been a huge uptick.

But if they get frustrated with that, my

concern is that they might start making

it -- try to make it mandatory, which is

really going to be a problem for our folks.

Anything new on the impact of copays?

Yeah, Bart?

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MR. BALDWIN: Yeah, just to comment on

the --

MS. SCHUSTER: KI-HIPP?

MR. BALDWIN: Yeah.

MS. SCHUSTER: Yeah.

MR. BALDWIN: I went to a couple of

meetings on this and was trying to dig down

why would anybody do this? Why? What's

the benefit? Because, I mean, your copays

stay at the Medicaid copay. So you don't

go to the health -- the commercial health

insurance, because -- I mean, we all know

that going off Medicaid onto commercial

health insurance is not a cost neutral

event.

MS. GUNNING: No.

MR. BALDWIN: I mean, it's much, much more

costly --

MS. GUNNING: Yeah.

MR. BALDWIN: -- to be on commercial -- any

type of plan. But you keep your Medicaid

copays. But, you know, really, the only

thing I found, unless you just really get a

huge promotion, you know, you can go off

Medicaid eventually. You're making a lot

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more money because of the benefit cliff.

But if there's potential to get other

members of your family covered through

this. So if you have a child that's on

Medicaid and -- for diagnosis reason, I

assume, but you can't -- your other members

of your family are not on any -- don't

qualify for Medicaid or can't afford the

commercial plan through an employer, then

could potentially get them essentially

covered -- the whole family covered under

Medicaid through this. They pay --

Medicaid will pay the premium for the whole

family if its cost -- if it meets their

cost --

MR. SHANNON: If it's cost effective for

Medicaid.

MR. BALDWIN: -- if it's cost effective for

Medicaid. And if you have a really high

needs, high-utilizer child, then that could

potentially still be cheaper for them to

pay the premiums versus those services. I

know that gets into the weeds, but I was

just trying to dig in what -- you know,

like you said, why would someone take on

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the responsibility of --


MR. BALDWIN: -- higher -- high risk, you

have to -- you know, it's riskier in a

sense. You have to pay the premiums and

get reimbursed, which that's a problem for

anybody, especially if you're at that

income level.


MR. BALDWIN: So I was trying to dig down,

what could be the potential benefit?

That's the only thing I could -- which

could be -- for some families, could be a

really good thing.

MS. SCHUSTER: Medicaid is arguing that it

expands the network for the individuals,

because they now have access to

non-Medicaid providers who are covered by

the employer's insurance plan.

MS. GUNNING: Not fully probably.

MS. SCHUSTER: Well, except that there's a

cost to it.

MS. GUNNING: Yeah, there's a cost.

MS. SCHUSTER: So I'm not -- I'm not so

sure that that's -- how much of a benefit

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that is.

MR. BALDWIN: Yeah, but I think --

MS. SCHUSTER: Is that your understanding,

too?

MR. BALDWIN: Yeah, yeah, I think --

MS. SCHUSTER: I mean, that's Medicaid's

argument that the people --

MS. GUNNING: That's the risk, though, for

the people.

MS. SCHUSTER: -- that the people would

have a greater range of providers. I don't

think -- I don't think that's true on the

behavioral health side, quite frankly.

MR. BALDWIN: No, I wouldn't think so.

Well, and they did say that in Kentucky --

which this number surprised me was this

high, but they said 92 percent of providers

in Kentucky are Medicaid of all the --

MS. SCHUSTER: I absolutely do not believe

that.

MS. GUNNING: No freakin' way. No freakin'

way.

MR. BALDWIN: I --

MS. SCHUSTER: I have heard that, too.

MR. BALDWIN: Because that was --

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MS. SCHUSTER: Not in dentistry, not

psychiatry.

MR. BALDWIN: I thought that would be

60 percent or 70 percent, so...

MS. GUNNING: Ain't no damn way.

MR. BALDWIN: Yeah. So...

MS. SCHUSTER: You know, we're hearing more

and more, even family practice

physicians --

MR. BALDWIN: Yeah.

MS. SCHUSTER: -- who are not taking

Medicaid. So to say that 92 percent of

providers are Medicaid providers is --

PARTICIPANT: Of all providers?

MS. SCHUSTER: Of all providers.

MR. BALDWIN: Not just behavioral health.

Yeah, I think that's --

PARTICIPANT: No.

MS. SCHUSTER: It's certainly not true of

psychology, I'll tell you that.

MS. GUNNING: No, absolutely not.

MS. SCHUSTER: Very few psychologists who

opted into --

MS. GUNNING: Not true. Not dentists. We

have one in all of Lexington.

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MR. BALDWIN: Well, and I -- and I wonder

if you just take in all providers, all

primary care and hospitals and everything.

By the time you get to -- the numbers

work -- may work out to 92 percent, but we

know for certain that psychologists in

certain areas it's nowhere near that.

So...

MS. MUDD: I'm looking at -- I've got -- it

looks like a PowerPoint. I don't know

where it came from. Oh, the Consumer

Rights and Client Needs TAC. Now it says,

Goals are -- designed to give Medicaid

members the tools to afford quality

comprehensive coverage in the commercial

marketplace while also saving Commonwealth

on healthcare expenses. Says this may make

family coverage more affordable and may

widen healthcare networks.

MS. SCHUSTER: Yeah.

MS. MUDD: There you go.

MS. SCHUSTER: That's what they're

claiming.

MR. BALDWIN: So you have -- would

potentially have access to providers you

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don't on Medicaid.

MR. SHANNON: Not behavioral health.

MS. SCHUSTER: Yeah, not behavioral health.

MS. GUNNING: You will also have to be very

careful to see only ESI providers who also

accept Medicaid.

MS. SCHUSTER: Yeah.

MR. BALDWIN: The risk of it.

MS. GUNNING: Well, since 92 percent do

that, it shouldn't be a problem.

MR. BALDWIN: I think in all this, the

waiver and getting folks off of Medicaid

and into a commercial plan, I just -- I

mean, we're about 15, 20 years past the

time where anybody thought commercial

health insurance was good.

MS. SCHUSTER: Yeah.

MR. BALDWIN: That's just speaking from my

own personal experience. I've paid more,

got -- for less for every year for the last

20 years.

MS. SCHUSTER: Yeah.

MR. BALDWIN: So --

MS. SCHUSTER: No. I think that's right.

MR. BALDWIN: -- and that's not --

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MS. GUNNING: I could buy a new house for

what mine --

MR. BALDWIN: -- commercial insurance in

general. I mean, everybody deals with that

personally. But I don't know how that's a

great move for anybody, but anyway.

MS. GUNNING: Although good game --

MS. SCHUSTER: Any new information on

impact of copays? Anybody heard any

stories? We're still trying to get the

word out about people, you know, at or

below 100 percent of the federal poverty

level. The Public Assistance Reform Task

Force meetings, we had a meeting this past

month in August. You-all will remember

House Bill 3 this last session that was

going to drug test everybody who's going to

get public assistance, was also going to

require people to have picture IDs in order

to use food stamps. We're going to put

work requirements in for KTAP and some

other programs.

And the bill didn't go any place, but

now they have created this task force. It

is co-chaired by Senator Stan Humphries from

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far western Kentucky, representative David

Meade from Lincoln County, who was one of

the co-sponsors of the original bill. Has

one democrat on it, Nima Kulkarni, who's a

freshman Democrat, an immigration attorney

from Louisville. Russell Webber from

Bullitt County, Republican. Whitney

Westerfield from Hopkinsville, the senator.

MR. BALDWIN: Max Wise.

MS. SCHUSTER: Max Wise, yeah, which is

interesting, from Taylor County.

We did get Bill Wagner on it. Bill

Wagner is the long-time head of the Family

Health Center, the FQHC in Louisville. And

he's been great at asking some really good

questions on this thing. Also, Elizabeth

Caywood, the Deputy Commissioner from DCBS,

has been actually a very positive member.

There's supposed to be a district court

judge, but nobody's ever shown up in that

spot.

We had some testimony. We were able

to give testimony last August 19th about

some of the problems with the

recommendations, and I gave a long diatribe

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about medically frail. And we really got

some good -- I thought some good attention,

particularly from Senator Westerfield, who's

also the legal counsel for Pennyroyal Comp

Care Center, who really was kind of

exercised by the time we finished about all

the problems with the attestation form and

these kind of things and wants to add to the

agenda having the Cabinet come and answer

some of the questions that we had about the

attestation form. So I thought that was

progress.

They were supposed to meet on

September 9th and they have cancelled that

meeting. They're going to meet twice in

October and then again in November. But

there are a lot of people that are trying to

make sure that the recommendations that come

out of this are not as onerous as House

Bill 3 was. Do you want to guess what the

amount of fraud is in SNAP and TANF? One

percent.

MS. GUNNING: I was going to say low.

MS. SCHUSTER: One percent. So they have

done all of this legislation around, you

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know, drug testing people and picture IDs

and all this stuff for a one-percent fraud

rate. And even some of the legislators who

clearly came thinking they were going to go

after waste, fraud and abuse were kind of

like, what, one percent. So that was very

positive, I thought. So we'll let you know

when the next -- the next meeting is. I

think it's -- I don't want to guess because

I can't remember. It's like October 9th

and then October 30th, but we'll let you

know.

I mentioned the teleconferencing. I

don't think that we need it because we

haven't had any trouble getting membership

here.

Mary, can you give us any update on

redesign of 1915(c) waivers? Are you still

on that committee?

MS. HASS: I'm still on that committee. I

can't give you any -- I don't think it's

going anywhere, because I know Johnny is on

there, too. I mean, personally? This is

my personal opinion. I think they're just

wanting us to rubber stamp some things they

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want to do. But I have seen nothing

productive come out of it, other than they

are doing some rate setting.

MR. CALLEBS: New rates coming out in the

fall.

MR. SHANNON: Yeah.

MS. HASS: And so...

MR. CALLEBS: Don't hold your breath if

you're a provider.

MS. HASS: The one gentleman felt positive

on the rate settings. I don't -- again,

I'm an advocate, so I really don't get into

what providers are being paid one way or

another. The ones that were on that seemed

to think that it was positive from what I

heard them say.

MR. SHANNON: Not everyone on it thinks

that way.

MS. HASS: Okay. That's what I'm saying.

MR. SHANNON: Knowing someone who serves on

it, that person has great reservations and

is not permitted to give details. But I

know it because I'm that person.

MS. HASS: But you're not -- are you on the

big advisory or --

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MR. SHANNON: No. I'm on the rate study.

MS. HASS: Okay. Thank you.

MR. SHANNON: My sense is that they have

made tweaks around the edges. They've

changed some programs; they've changed some

definitions. Two waivers are seeing a

fairly large reduction overall in terms of

dollars, you know, close to 10 percent.

PARTICIPANT: Did he say reduction?

MS. SCHUSTER: Reduction.

MR. SHANNON: Yes, reduction. The cost --

MS. GUNNING: Ten (10) percent in each one,

Steve?

MR. SHANNON: The category of the waiver is

receiving about a 10 percent reduction.

And there's six waivers, so four are not.

It has to be budget neutral. So when they

made changes, there essentially has to be

losers if there's any winners at all, so --

but it's not going to be available, I don't

think -- maybe October is when they're

going to release it to you-all.

MS. HASS: So we have a meeting coming up

on September the 12th --

MR. SHANNON: Okay. Maybe it's then.

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MS. HASS: -- is the next -- is the next --

MR. SHANNON: Hopefully -- okay, you should

see it then.

MS. HASS: But if you ask my general

opinion, my general opinion, I do not see

much good that has come out of it. You

know, again a couple things that I had

off -- you know, that I was concerned

about, it's going back to give it to the

comment line and have I gotten any --

MR. SHANNON: Right.

MS. HASS: -- comment back on the comments

I made? No. So, again, I sit on the big

committee, so -- I mean, I'm not overly

enthused. Maybe after September 12th I'll

be a little bit more enthused. But right

now I just -- I just feel like it's rubber

stamp and -- the one thing that I feel most

negative about is that -- and I brought

this up to two or three senators, is that

the families that I recommended to be on --

someone like the case management, quality

of care person directed, all of -- well,

excuse me. Of the four families I

recommended, three of them resigned just

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because they felt like they were not being

taken seriously. And these are people who

have individuals accessing the Medicaid

system. And these are people with very

severe behavioral issues and brain injury

on top. They're behavioral issues and

brain injury issues. So that's what I'm

most about. And I will bring that up on

the September 12th meeting that I felt

that, again, the families were really not

taken seriously on the subcommittees.

MR. CALLEBS: One other big change, Sheila,

around case management is that the case

managers are going to be given the

authority to prior authorize services, and

care-wise remove from that equation, so

taken out as the middle man. So when care

managers go into MWMA and put in a plan,

they will automatically generate PAs and be

able to theoretically kind of streamline

that --

MR. SHANNON: That should expedite the

process.

MR. CALLEBS: -- plan approval so that you

can access services and maybe decrease

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potential for gaps in there. So I think

most people say that's a positive move.

MS. SCHUSTER: Yeah.

MR. CALLEBS: With a lot of training

upfront, make sure it goes well, but -- so

that's coming as well by the end of the

year --

MS. SCHUSTER: Okay.

MR. CALLEBS: -- with the case managers.

MR. BALDWIN: With the case managers. Can

the case managers request the PAs or --

when they put it in the treatment plan it

automatically generates --

MR. CALLEBS: For most services. Some of

the higher cost services will still require

Medicaid approval, but even still, you can

get the kind of bread and butter services

approved and PAs will automatically

generate. And it will be a single PA, I'm

told, that will be present on MWMA, that

every --

MR. SHANNON: Which is an online management

system, MWMA.

MR. CALLEBS: Yes. And every provider on a

person's plan can go in and see -- see the

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PA and the units and the approvals. There

will no longer be PAs -- multiple PAs

generated and sent out to all providers on

the plan. Go to MWMA see a single PA for

that person. We're told. So that's the

plan.

MS. SCHUSTER: So what's --

PARTICIPANT: That's a good question --

MS. SCHUSTER: -- what's the overall

timeline on this thing? I mean, is there

going to be an end to this at some point?

MR. CALLEBS: I was told --

MS. SCHUSTER: It feels like it's been

going on forever, so...

MR. CALLEBS: Oh, specifically for the PA.

MS. SCHUSTER: No, no. I meant for the --

for the whole redesign --

MR. SHANNON: The Navigant, the redesign.

MS. SCHUSTER: -- the Navigant redesign.

MR. SHANNON: I think that they're still

wrapping up kind of overarching changes.

And then they'll get into more detail in

Phase 2.

MR. CALLEBS: In 2020. I think it will run

all through 2020 is my --

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MR. SHANNON: Yeah. I mean, it's...

MS. HASS: At a cost of what?

MS. SCHUSTER: Okay. So we have that to

look forward to.

Anything else, Mary, on the ABI

services?

MS. HASS: Yes, I have a couple things. On

ABI services the good news is -- and a

couple people here remember when I

questioned the amount of slots that ABI had

on their long-term care and that we were

accessing all of those, well, somebody in

the ABI branch -- and I see nobody from

Medicaid is here, I wanted to bring this

up -- they found 27 additional ABI

long-term care slots, which we are very

appreciative of. That means 27 people who

have been on the long waiting list are

receiving care now.

MS. SCHUSTER: Wow, good.

MS. HASS: So that was good news.

MS. SCHUSTER: Did they take them away from

short term or did they just find --

MS. HASS: No, no, no. No, the acute.

There's the two, the acute --

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MS. SCHUSTER: Acute.

MS. HASS: -- and the long-term --

MS. SCHUSTER: Yeah.

MS. HASS: -- long-term care. No, that

they have to be -- they were all long-term

care. Those were where our longest waiting

list was. At the present -- or, excuse me.

When those came out, there was not a

waiting list for acute, but I did hear the

other day that there are a few people now

waiting on the acute. I do not know the

exact numbers since I'm not getting any

comments back. So we'll continue on the

search.

The thing that's most troubling to me,

and this is brought up to me by both a

provider and a family member, is, is that if

you're under the acute care, that they are

telling the family that they -- if they have

been on there for a fairly long term, say,

over two years, they will then have to

decide to go on the long-term care. But

right now, there's a waiting list. So

you're receiving services under the acute,

but then you would have to go under the

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long-term care. Now, I've not gotten a

response back on that, but that's very, very

troubling, because you can have somebody

who's been receiving services. And a lot of

our folks the reason that they were under

the acute is because there's a lot of

behavioral issues. So we argued for that

that they were able to stay under the acute

because of their more heavily needs, or

whatever, and that they were better served

under the acute, which we all recognize

acute initially was for rehab only, but

that's not the way it has worked out in the

process. So I'm trying to get answers on

that.

And then the other thing that we're

working on, both Diane and I are working

on --

MS. SCHUSTER: Wait. Hold on a minute.

MS. HASS: Sure.

MS. SCHUSTER: Let me go back to this. Are

they telling people if they are on acute

for two years plus, or some length of time,

that they have to get off --

MS. HASS: Yes.

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MS. SCHUSTER: -- acute?

MS. HASS: Yes.

MS. SCHUSTER: So they have to empty out

that slot, make that slot available to

acute and -- but there is no slot over in

long-term care.

MS. GUNNING: Right.

MS. SCHUSTER: So are they without services

at that point?

MS. HASS: Yes.

MS. GUNNING: Right.

MS. HASS: Yes. So we haven't got that --

it has not happened in reality. But,

again, it makes no sense. So, again, I'm

working on that issue trying to -- so

anyway. So right now it's -- and for the

families who have been told that,

especially if you have someone who has --

the one family that I'm working real hard

with right now, the one that was told this,

the person has severe needs. I mean,

unfortunately, there are a lot of

behavioral issues that are not going to be

able to be served under the long-term care.

It's just not.

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MS. SCHUSTER: And there is no other --

MS. HASS: Well, we have two -- we have two

waivers: Acute, long-term care.

And, you know, then we have other

folks who are coming into the system that,

you know, they're automatically all going to

long-term care, which I can't understand.

Yes, this person was fairly far post, but

never received any type of rehab initially.

So I'm arguing that case. I'm working on

that one, too. But those are just a couple

issues which I was hoping Medicaid would be

here that I could ask that.

MS. SCHUSTER: They boycott us because we

meet over here.

MS. HASS: I know, I understand. I

understand. Bad people.

So anyway, and the other thing that

Diane and I are working with again relates

back to the waivers, is that we are seeing

with the right supports a lot of our folks

can be employable. We have a doctor at UK,

Peter Meulenbroek -- and I probably

butchered his last name, so I -- forgive me

about that. But he has done a series of

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studies and he's researching that on

people -- not just brain injury, but -- his

main focus is brain injury and a couple

other spinal cord injuries, and there's one

other and I can't remember what it is right

now. But anyway, but he's showing great

progress. He's working with two or three of

our clients who are in the waiver.

So my thing is, how can we get his

services. Now, he's got a -- he's got a

grant right now paying for it going back,

because under the waiver they say supportive

employment will not pay for these services.

I know. I know. So anyway, so I'm working

on that. Those are the issues I'm working

on right now.

MS. SCHUSTER: Okay. We're very glad we

have you, Mary, and Diane as well.

MS. HASS: Well, and Diane has done a

lot -- the way this is really evident,

Diane is really the clinical person and

then I take the studies and I reach it down

into how it's going to affect real families

and -- and real people. So, you know, it's

a good partnership.

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MS. SCHUSTER: So going into the 2020

session, are you-all fighting for more

long-term care slots?

MS. HASS: Yes. All this is to be

determined.

MS. SCHUSTER: Okay.

MS. HASS: We're literally right now

working with the National Brain Injury

Association, because we're looking at our

agenda. We'll definitely do the helmets

again on children. And then we're looking

whether it should be a commission on brain

injury; should there a department of rehab.

How do we get these issues really addressed

for people with brain injuries.

MS. SCHUSTER: Okay.

MS. HASS: But those -- those are to be

determined because we're still in the

process right now working on those.


MS. HASS: And working on bill sponsors.

MS. SCHUSTER: Thank you. I think we have

lots of recommendations. I'm not looking

for any more because we have about ten.

MS. HASS: No.

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MS. SCHUSTER: Other issues and updates

from anyone?

MR. SHANNON: I have an update on the

nonemergency transportation.

MS. SCHUSTER: All right, Steve.

MR. SHANNON: I looked at the reg. And the

reg says, the person needs to use a

stretcher. Yeah, nonemergency, 907 KAR

1:060. This is ambulance ride with

nonemergency ambulance services, a

nonemergency ambulance service who --

within -- to provide within a medical

service area shall be covered if the

recipient's medical condition warrants

transport by stretcher.

MS. SCHUSTER: But nobody has said that to

you?

MR. KELLY: No. Ambulatory. They said if

they're ambulatory.

MR. SHANNON: They don't need a stretcher.

MS. GUNNING: We'll put everybody on the

stretcher.

MR. SHANNON: Yeah. Warrants transport

by --

PARTICIPANT: Can't walk -- put them on a

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stretcher.

MR. SHANNON: But, again, if you're --

PARTICIPANT: Put them on a stretcher.

MR. SHANNON: Wait, wait, hold on. If you

don't want to transport the person, you're

going to say, it doesn't warrant a

stretcher.

PARTICIPANT: Right.

MR. SHANNON: So it's a Medicaid problem;

it's the reg problem.

MS. SCHUSTER: What's the reg number?

MR. SHANNON: 907 KAR 1:060.

MS. SCHUSTER: Okay. Good for you.

PARTICIPANT: Has it always been that way,

Steve, or is that a recent change?

MR. SHANNON: I didn't check. I think it's

always been that way.

MS. SCHUSTER: I think it probably has

been.

MR. SHANNON: Medicaid has no interest on

putting the reg on hold, the emergency

piece.

They aren't being put on hold to

Stephanie Bates' knowledge.

MS. SCHUSTER: Are you talking about the

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BHSO regs?

MR. SHANNON: BHSO regs.

MS. SCHUSTER: Okay.

MR. SHANNON: Comments submitted by the BH

TAC during the comment period.

MS. SCHUSTER: They were submitted by the

Kentucky Mental Health Coalition.

MR. SHANNON: Yeah, so there's comments.

MS. SCHUSTER: Yeah.

MR. SHANNON: But I think that's her

insight that -- and I never thought the BH

TAC could submit comments. I mean, we

could, but other people didn't.

MR. BALDWIN: That's interesting.

MR. SHANNON: Now we know.

PARTICIPANT: Can we collect all of ours

and we submit them as a group?

MS. SCHUSTER: Yeah, yeah, we could.

MR. SHANNON: Yeah, and missed the date.

MR. BALDWIN: The TAC. Yeah, they got

plenty of comments.

MR. SHANNON: They got comments. But going

forward, TACs ought to be submitting

comments, right? That's the message from

that e-mail.

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MS. MUDD: I thought we weren't allowed to

talk to anybody but the MAC.

MR. SHANNON: It's comments.

MS. SCHUSTER: Is that consistent with our

big advisory to the MAC?

MR. SHANNON: She asked if they were

submitted. That must mean they're allowed.

MR. BALDWIN: Maybe Stephanie is trying to

give us a little do this and try this.

MR. SHANNON: I got to be in Lexington at

4:00.

MS. SCHUSTER: The golden rod sheet, one

side are managed care forums that the MCOs

are having for all providers. So I'll get

this to you electronically. You can send

it out. The other side are a series of

advocacy training that Kentucky Voices for

Health and other organizations working with

them. They're really neat. What we do is

do the first hour and a half. It's about

Medicaid and SNAP and TANF, and the census,

and housing and mental health and substance

use. In other words, issues briefing. And

then the second half is my super-duper

Dr. Schuster, everybody should be an

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advocate. And you just really don't want

to miss that. So these are free. Sign up.

We're coming to Morehead. Did you see

that? Okay. So spread those around.

We are not meeting on election day.

We changed that meeting to the Monday,

November the 4th. We'll be here in the

annex at 1:00. And then the MAC meeting is

September 26. And we are adjourned if

nobody else has anything else to add.

MR. KELLY: So moved.

MS. SCHUSTER: So moved. All right. Take

care. Thank you all very much.

* * * * * * *

THEREUPON, the proceedings concluded at

3:02 p.m.

* * * * * * *

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STATE OF KENTUCKY )

COUNTY OF FAYETTE )

I, JOLINDA S. TODD, Registered

Professional Reporter and Notary Public in and for

the State of Kentucky at Large, hereby certify that

the foregoing record represents the original record

of the proceedings of the Behavioral Health

Technical Advisory Committee; the record is an

accurate and complete recording of the proceeding;

and a transcript of this record has been produced

and delivered to the Department of Medicaid

Services.

My commission expires: August 24, 2023.

IN TESTIMONY WHEREOF, I have hereunto set my hand and seal of office on this the 27th day of September 2019.

JOLINDA S. TODD, RPR, CCR(KY) NOTARY PUBLIC, STATE AT LARGE

ID# 449787

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Documents

2 * * * * * * * * * * * 7 8 9 10 11...2019/09/03 · MR. HANNAH: Dave Hannah with Passport. MR. CAIN: Micah Cain with Passport. MS. WHITE: I'm Shannon White with Centerstone Kentucky